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INTANCV  AM>  (  IIILDIIOOI). 


A  TREATISE 


ON  THE 


DISEASES 


OP 


INFANCY  AND  CHILDHOOD. 


SECOND    EDITION, 


ENLARGED    AND    THOROUGHLY    REVISED, 


BY 

J.  LEWIS  SMITH,  M.D., 

CURATOR  TO  THE  NURSERY  AND  CHILD'S  ni)8PITAI,,  NF.W  VORK  I    PHV8ICIAN  TO  THE  INFANTS' 

H08PITAI,,  ward's  island;    consulting  PHYBICIAN  is  THE  CLASS  OF  CHILDREN'S 

DISEASES,  OUT-DOOR  DEPARTMENT  OF  BELLKVUE  HOSPITAL;    CLINICAL 

LECTURER    ON    DISEASED   OP  CHILDREN,  AND  PROFESSOR    I.V 

BELLBVUB  HOSPITAL  MF.DICAL  COLLEGE, 

NEW  YORK. 


TMI  I  LA  DELI'  JI  J  A  : 

n  E  N  Tl  Y     O .    LEA. 

1872. 


Entered  according  to  Act  of  Congress,  in  the  year  1872,  by 

HENRY     C.    LEA, 

in  the  Office  of  the  Librarian  of  Congress,  at  Washington.     All  rights  reserved. 


PHILADELPHIA: 
COLLI  NS,     PRINTER. 


PREFACE  TO  THE  SECOND  EDITION. 


The  purpose  of  the  author  has  been  to  present  a  description  of 
the  diseases  of  infancy  and  childhood  succinctly,  but  at  the  same 
time  in  a  sufficiently  comprehensive  manner  to  meet  the  require- 
ments of  the  medical  student  and  practitioner.  He  has  endeavored 
to  incorporate  in  the  treatise  all  recently  ascertained  facts  relating 
to  this  branch  of  medical  practice,  and  especially  has  it  been  his 
endeavor  to  recommend  such  modes  of  treatment  as  comport  with 
and  are  suggested  by  our  present  knowledge  of  the  pathology  of 
early  life,  the  efficacy  of  hygienic  measures  in  the  treatment  of 
the  young,  and  the  recuperative  powers  of  the  system  at  this  age. 

While  the  author  has  respected  the  opinions  of  previous 
writers,  and  has  adopted  them,  so  far  as  they  appeared  to  be 
correct,  he  has  depended  much  more  for  the  material  of  his 
treatise  on  clinical  observations  and  the  inspection  of  the- 
cadaver.  I^Tecessarily,  as  a  result  of  independent  investigations,, 
opinions  are  now  and  then  expressed  different  from  those  which 
are  commonly  accepted.  ISTovel  views  have  not,  however,  been 
presented,  unless  the  author  was  fully  satisfiecj  that  they  were 
substantiated  by  a  sufficient  number  of  observations. 

In  presenting  to  the  profession  the  second  edition  of  his  work,, 
the  author  gratefully  acknowledges  the  favorable  reception  ac- 
corded to  the  first.  He  has  endeavored  to  merit  a  continuance 
of  this  approbation  by  rendering  the  volume  much  more  com- 
plete til  an  before.     Nearly  twenty  additional  diseases  have  been 


VI  PREFACE    TO    THE    SECOND    EDITION. 

treated  of,  among  which  may  be  named  Diseases  Incidental  to 
Birth,  Rachitis,  Tuberculosis,  Scrofula,  Intermittent,  Remittent, 
and  Typhoid  Fevers,  Chorea,  and  the  various  forms  of  Paralysis. 
Many  new  formulse,  which  experience  has  shown  to  be  useful, 
have  been  introduced,  portions  of  the  text  of  a  less  practical 
nature  have  been  condensed,  and  other  portions,  especially  those 
relating  to  pathological  histology,  have'"been  rewritten  to  correspond 
with  recent  discoveries.  Every  etfort  has  been  made,  however,  to 
avoid  an  undue  enlargement  of  the  volume,  but,  notwithstanding 
this,  and  an  increase  in  the  size  of  the  page,  the  number  of  pages 
has  been  enlarged  by  more  than  one  hundred. 

227  West  49Tn  Street,  New  York, 
April,  1872. 


CONTENTS. 


PART  I. 

CHAPTER   I. 

PAGK 

Infancy  and  Childhood 17 

CHAPTER    II. 
Cake  of  the  Mother  in  Pregnancy 20 

CHAPTER    III. 

Mortality  of  early  Life — its  Causes  and  Prevention         ...      23 

CHAPTER    IV. 

Lactation 28 

Hindrances  to  Lactation,  and  physical  conditions  rendering  it  Im- 
proper— Facts  and  Rules  in  reference  to  Lactation — Human  Milk — 
Modifications  of  the  Milk  in  consequence  of  the  Diet — Modification 
of  Milk  from  its  retention  in  the  Breast^ — Modification  of  Milk  from  Age 
and  Nervous  Impressions — Modification  of  Milk  by  the  Catamenial 
Function  and  Pregnancy — Quantity  of  Breast  Milk  required  by  the 
Infant — Differences  in  Suckling  Women  as  regards  Quantity  and 
Quality  of  Milk — Scantiness  of  Milk  ;  its  Causes  and  Treatment. 

CHAPTER    Y. 

Selection  of  a  Wet-Nurse 49 

CHAPTER    VI. 
Course  of  Lactation — Weaning         , 54: 

CHAPTER    VII. 

Artificial  Feeding 57 

Composition  of  milk. 

CHAPTER    VIII. 

Baths — Clothing 60 


Vlll  CONTENTS. 


CHAPTER    IX. 

PAGE 

Accidents  and  Ailments  incidental  to  the  Birth  of  the  Infant,  and 

Detachment  op  the  Cord 63 

Apnoea  (Aspliyxia)  Neonatorum — Causes — Treatment — Caput  Succe- 
daneum — Ceplialfematoma. 

CHAPTER    X. 

Conjunctivitis  op  the  New  Born 65 

Causes — Symptoms — Treatment. 

CHAPTER   XI. 

Diseases  op  the  Umbilicus 69 

Inflammation  of  the  Umbilical  Vein  and  Arteries — Treatment — Inflam- 
mation and  Ulceration  of  Umbilicus — Treatment — Umbilical  Granula- 
tions or  Fungus — Treatment. 

CHAPTER    XII. 

Umbilical  Hemorrhage 72 

Sex,  Age — Causes — Symptoms — Prognosis — Treatment. 

CHAPTER    XIII. 

Diagnosis  of  Infantile  Diseases 76 

General  Observations — Features,  External  Appearance  of  Head,  Trunk, 
and  Limbs  in  Disease — Attitude — Movements — Tlie  Voice — Respiratory 
System — Respiration  in  Health — Respiration  in  Disease — Circulatory 
System — Pulse  in  Health — Pulse  in  Disease — Animal  Heat — Digestive 
System — Nervous  System,  Pain. 


PART  II. 

CONSTITUTIONAL  DISEASES. 

SECTIOIn"  I. 
DIATHETIC  DISEASES. 

CHAPTER    I. 

Rachitis 91 

Age — Anatomical    Characters — Craniotabes  —  Symptoms  —  Complica- 
tions— Diagnosis — Prognosis — Treatment. 

CHAPTER    II. 

Scrofula 104 

Causes — Anatomical  Characters — Symptoms — Relation  of  Scrofula  to 
Tuberculosis — Prognosis — Treatment :  Prophylactic  ;  Curative. 


CONTENTS.  IX 


CHAPTER    III. 

PAGE 

Tuberculosis 122 

Etiology — General  Anatomical  Characters  of  Tuberculosis — Anatomi- 
cal Characters  in  Infancy  and  Childhood— Lungs— Abdominal  Viscera 
— Stomach  and  Intestines— Symptoms — Bronchial  Glands — Physical 
Signs — Lungs — Pleura — Stomach  and  Intestines — Prognosis — Treat- 
ment :  Prophylactic ;  Curative. 

CHAPTER    IV. 

Syphilis 149 

Etiology— Clinical  History— Manifestations— Coryza— Mucous  Patches 
—Roseola— Pemphigus  — Acne,  Impetigo,  and  Ecthyma  — Visceral 
Lesions — Prognosis— Treatment. 


SECTIOl^  II. 

ERUPTIVE  FEVERS. 

CHAPTER    I. 

Measles 159 

Symptoms — Complications :  Capillary  Bronchitis,  True  Croup,  Pneu- 
monitis— Anatomical  Characters — Nature  —  Diagnosis  —  Prognosis — 
Ti'eatment. 

CHAPTER    II. 

ScAKLET  Fever 169 

Symptoms,  Regular  Form  ;  Irregular  Form ;  Malignant  Form — Com- 
plications :  Gangrene  of  Mouth,  Articular  Rheumatism,  Serous  Inflam- 
mation— Sequelae  :  Nephritis,  Otorrhcea — A  Case — Anatomical  Char- 
acters—Natvire — Diagnosis — Prognosis — Treatment — Prophylaxis. 

CHAPTER    III. 

Variola — Varioloid 201 

Incubative  Period— Stage  of  Invasion— Stage  of  Eruption— Stage  of 
Desiccation — Desquamation — Varioloid — Mode  of  Death — Anatomical 
Characters — Complications — Prognosis— Diagnosis — Treatment. 

CHAPTER    IV. 

Vaccinia 212 

History  of  Vaccination— Appearances,  Symptoms,  Anomalies,  Compli- 
cations, and  Sequelae  —  Subsequent  Vaccinations  — Protection  from 
Vaccination — Revaccination — Selection  of  Virus. 

CHAPTER    V. 

Varicella 224 

Incubative  Period— Symptoms— Diagnosis— Prognosis— Treatment. 


X  CONTENTS. 

SECTIO]^  III. 

NON-ERUPTIVE  CONTAGIOUS  DISEASES. 
CHAPTER    I. 

PAGE 
DiPHTHEKIA 237 

Anatomical   Characters  —  Symptoms — Nature — Sequelae — Prognosis — 
Diagnosis — Treatment. 

CHAPTER    II. 

Pertussis 247 

Symptoms — Comjilications — Convulsions — Bronchitis — Pneumonitis — 
Thrombosis — Diagnosis — Prognosis — Treatment. 

CHAPTER    III. 

Parotiditis 261 

Nature — Diagnosis — Treatment. 

SECTIOI^  IV. 

OTHER  GENERAL  DISEASES. 

CHAPTER    I. 

Intermittent  Fever 263 

Symptoms — Prognosis — Treatment. 

CHAPTER    II. 

Remittent  Feter 267 

Symptoms — Diagnosis — Treatment. 

CHAPTER    III. 
Typhoid  Fever 269 

Causes — Anatomical  Characters — Symptoms — Complications — Diagno- 
sis— Duration — Prognosis — Treatment. 

CHAPTER    IV. 

Acute  Rheumatism 277 

Causes — Symptoms — Duration — Prognosis— Diagnosis — Treatment. 

CHAPTER    V. 

Erysipelas 384 

Table  of  Cases — Age — Point  of  Commencement— Causes — Premonitory 
Symptoms— Symptoms  — Prognosis  — Duration— Modes  of  Death  — 
Pathological  Anatomy — Treatment. 


CONTENTS.  xi 

PART  III. 

LOCAL  DISEASES. 


SECTION"  I. 

PAGE 

DISEASES  OF  THE  CEREBRO-SPINAL  SYSTEM    .        .     290 

CHAPTER    I. 

AcEPHALUs — Anencephalus 298 

Anatomical  Characters — Symptoms — Prognosis. 

CHAPTERII. 
Impekfect  Bkain 299 

A  Case — Symptoms — Prognosis — Microceplialus — Atrophy  of  brain. 

CHAPTER    III. 

Hypertrophy  op  Brain 303 

Pathological    Anatomy — Causes — Cretinism — Symptoms — A    Case — 
Diagnosis — Prognosis — Treatment. 

CHAPTER    lY. 

Thrombosis  in  the  Cranial  Sinuses  (Phlebitis) 308 

Anatomical   Characters — Causes  ;  from  Otitis — Symptoms — Diagnosis 
— Prognosis — Treatment. 

CHAPTER    V. 

Congestion  of  Brain 314 

Active   and    Passive — Causes — Symptoms — Anatomical   Characters — 
Prognosis — Treatment. 

CHAPTER    YI. 

Intra-Cranial    Hemorrhage    (Meningeal    Hemorrhage — Cerebral 
Hemorrhage) 319 

Causes — Anatomical  Characters — Symptoms — Diagnosis — Prognosis — 
Treatment. 

CHAPTER   YII. 

Congenital  Hydrocephalus 380 

Anatomical   Characters  —  Symptoms  — Diagnosis — Prognosis  —  Treat- 
ment. 

CHAPTER   YIII. 

Acquired  Hydrocephalus 338 

Causes — Anatomical  Characters — Location  and   Quantity  of  Fluid — 
Symptoms — Prognosis — Treatment. 


XU  CONTENTS. 


CHAPTER    IX. 

PAGE 

Meningitis,  Simple  and  Tubercular 341 

Age  — Anatomical  Characters — Causes — Premonitory  Stage — Symp- 
toms— A  Case — Diagnosis — Prognosis — Treatment. 

CHAPTER    X. 

Spurious  Hydrocephalus 363 

Anatomical  Characters — Symptoms — Cases — Diagnosis — Prognosis — 
Treatment. 

CHAPTER    XI. 

Eclampsia 369 

Essential,  Symptomatic,  Sympathetic,  General,  and  Partial — Causes — 
Premonitory  Stage — Symptoms — Anatomical  Characters — Diagnosis 
— Prognosis — Treatment. 

CHAPTER    XII. 

Tetanus  Infantum 383 

Table  of  Cases — Period  of  Commencement — Frequency  in  Certain 
Localities — Causes— Symptoms — Prognosis — Mode  of  Death — Duration 
in  Fatal  Cases — Duration  in  Favorable  Cases — Diagnosis — Preventive 
Treatment — Treatment. 

CHAPTER    XIII. 

Internal  Convulsions 405 

Different  Forms — Causes — Anatomical  Characters — Symptoms — Case 
— Diagnosis — Prognosis — Modes  of  Death — Treatment. 

CHAPTER    XIV. 

Chorea 415 

Age  —  Causes  —  Sex  — Uterine  Irritation  — Anaemia  —  Rheumatism — 
Fright — Imitation — Intestinal  Irritation — Lesions  of  Brain  and  Spinal 
Cord  —  Anatomical  Characters  —  Symptoms — Prognosis  —  Course  — 
Diagnosis — Treatment :  Regimenal ;  Medicinal. 


CHAPTER    XV. 

Infantile  Paralysis 431 

Symptoms  —  Progress — Etiology — Anatomical   Characters — Diagnosis 
— Prognosis — Treatment. 


^Ci' 


CHAPTER    XVI. 

Facial  Paralysis 440 

Causes — Symptoms — Prognosis— Treatment.  Paralysis  with  Apparent 
Hypertrophy  :  Symptoms — Anatomical  Characters — Causes— Progno- 
sis— Treatment. 


CONTENTS.  xiii 

SECTION  11. 

DISEASES  OF  THE  KESPIRATORY  SYSTEM. 
CHAPTER    I. 

PACK 
CORYZA 445 

Causes — Anatomical  Characters — Symptoms — Prognosis — Treatment. 

CHAPTER    II. 

Simple  Laryngitis 449 

Symptoms  —  Chronic    Form — Anatomical    Characters  —  Treatment. 
Spasmodic  Laryngitis :  Causes — Symptoms — Anatomical  Characters — 
Pathology — Diagnosis — Prognosis — Treatment. 

CHAPTER    III. 

Pseudo-Membranotts  Laryngitis 458 

Causes — Anatomical  Characters — Symptoms — Pathology — Diagnosis — 
Prognosis — Treatment — Tracheotomy. 

CHAPTER    lY. 

Bronchitis 477 

Causes — Anatomical  Characters — Symptoms — Capillary  Bronchitis — 
Diagnosis — Prognosis — Treatment. 

CHAPTER    Y. 

Pneumonitis 490 

Catarrhal,  Croupous,  and  Interstitial — Causes — Hypostasis — Anatomi- 
cal Characters — Cheesy  Pneumonitis — Symptoms — Physical  Signs — 
Diagnosis — Prognosis — Treatment. 

CHAPTER    YI. 

Pleuritis 507 

Causes  —  Cases  —  Anatomical  Characters  —  Empyema  —  Symptoms — 
Physical  Signs — Case — Diagnosis — Prognosis — Treatment — Thoracen- 
tesis. 

SECTION"  III. 

DISEASES  OP  THE  DIGESTIVE  APPARATUS. 

CHAPTER    I. 

Simple  Stomatitis  ;  Ulcerous  Stomatitis  ;  Follicular  Stomatitis  .  525 
Simple  or  Erythematic  Stomatitis:  Causes — Symptoms — Appearances 
— Treatment.  Ulcerous  Stomatitis  :  Anatomical  Characters — Causes 
— Symptoms — Diagnosis— Prognosis — Treatment.  Follicular  Stoma- 
titis :  Anatomical  Characters — Causes — Symptoms — Diagnosis — Prog- 
nosis— Treatment. 


XIV  CONTENTS, 


CHAPTER   II. 

PAGE 

Thrush ' 533 

Anatomical  Characters — Description  of  the  Oidium  Albicans — Symp- 
toms— Causes — Diagnosis — Prognosis — Treatment. 

CHAPTER  III. 

Gangrene  of  the  Mouth 538 

Anatomical  Characters — Age — Causes — Symptoms — Diagnosis — Prog- 
nosis— Treatment. 

CHAPTER    lY. 
Dentition 546 

Pathological  Results  of  Dentition — Diagnosis — Treatment — Scarifica- 
tion of  the  Gums — Second  Dentition. 

CHAPTER    y. 

Simple  Pharyngitis  ;  Peri-Phaetngeal  Abscess  ;  (Esophagitis   .        .     555 
Pharyngitis :  Anatomical  Characters — Causes— Symptoms — Prognosis 
— Diagnosis — Treatment.      Peri-Pharyngeal   Abscess  :  Age — Cause — 
Anatomical  Characters — Symptoms — Duration — Diagnosis — Prognosis 
— Treatment.     (Esophagitis :  Anatomical  Characters — Treatment. 


CHAPTER   VI. 

Indigestion  ;  Congestion  op  Stomach  ;  Gastritis  ;  Follicular  Gas- 
tritis ;  Diphtheritic  Gastritis  ;  Post-Mortem  Digestion  ;  Soft- 
ening      567 

Indigestion  :  Causes — Symptoms — Prognosis — Treatment.  Conges- 
tion of  the  Stomach.  Gastritis  :  Causes — Age — Symptoms— Anatomi- 
cal Characters — Diagnosis — Prognosis — Treatment.  Follicular  Gas- 
tritis ;  Diphtheritic  Gastritis ;  Post-Mortem  Digestion ;  Gelatinous 
Softening ;  White  Softening. 

CHA  PTER    YII. 

Diarrhoea 585 

Non-Inflammatory  Diarrhoea :  Causes — Symptoms — Anatomical  Char- 
acters— Diagnosis — Prognosis — Treatment. 

CHAPTER    YIII. 

Intestinal  Inflammation  op  Infancy 593 

Causes — Age — Sj-mptoms — Microscopic  Character  of  the  Stools — Pulse 
— Anatomical  Characters — Condition  of  the  Liver — State  of  the  Brain 
— Diagnosis — Prognosis — Treatment,  Regimenal  Measures,  Medicinal 
Treatment  ;  Enemata,  External  Treatment. 

CHAPTER    IX. 

Enteritis  and  Colitis  in  Childhood 630 

Causes — Symptoms — Diagnosis — Prognosis — Treatment. 


CONTENTS.  XV 

CHAPTER    X. 

PAGE 

Cholera  Infantum G24 

Definition  of  the  Term — Causes — Its  Prevalence  in  tlie  Cities — Symp- 
toms— Anatomical  Characters — Diagnosis — Prognosis — Treatment. 

CHAPTER    XI. 

Intestinal  Worms 633 

Five  Kinds — Description  of  them — Causes— Symptoms  of  Lnmbrici — 
Diagnosis — Prognosis — Treatment — Use  of  Santonin,  Spigelia,  Cheno- 
podium. 

CHAPTER    XII. 

Gastro-Intestinal  Hemorrhage 646 

Three  Varieties — Causes — Prognosis — Treatment. 

CHAPTER    XIII. 

Intussusception 652 

Intussusception  without  Symptoms — Intussusception  with  Symptoms 
— Previous  Health — Causes — Age — Seat  and  Pathological  Anatomy — 
Intussusception  in  the  Small  Intestines — Cases — Intussusception  in  the 
Large  Intestines  —  Symptoms  —  Diagnosis  —  Duration —  Prognosis  — 
Mode  of  Death — Treatment. 


SECTIOIvr  IV. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

CHAPTER    I. 

Cyanosis 674 

Literature  of  Cyanosis — Sex — Causes  of  the  Malformation — Symptoms 
—  Prognosis  —  Mode  of  Death  —  Modes  of  Compensation — Morbid 
Anatomy — Theories  Relating  to  the  Etiology  of  Cyanosis — Treatment. 

SECTIOISr  V. 

SKIN  DISEASES. 

CHAPTER  I. 

Erythematous  Diseases 695 

Erythema  :  Two  Forms ;  Idiopathic,  Symptomatic — Prognosis — Diag- 
nosis— Treatment.  Roseola  :  Symptoms — Causes — Prognosis — Diag- 
nosis— Treatment.  Urticaria  :  Causes — Prognosis — Diagnosis — Treat- 
ment. 

CHAPTER    II. 

Papular  Diseases 703 

Lichen — Prurigo — Stropliulus — Treatment. 


XVI  CONTENTS. 


CHAPTER    III. 

PAGE 

Eczema  and  Scabies 704 

Eczema ;  Simplex,  Rubrum,  and  Impetiginodes— Symptoms — Diagno- 
sis— Treatment :  General ;  Local.     Scabies :  Diagnosis — Treatment, 


APPENDIX. 

A.— Dietary  Formttl^ 714 

Falkland's  Method  of  Preparing  Milk  for  Infants — Lobb's  Method — 
Meigs'  Preparation — Liebig's  Soup — Hassell's  Comments — Raw  Meat 
— Beef-tea — Liebig's  Beef-tea — Hogarth's  Essence  of  Meat — Ronth's 
Comments. 

B. — Remarks  on  the  Prevention  op  Scarlet  Fever.    By  Wm.  Budd, 
M.D 720 

C. — Remarks  on  the  Diphtheritic  Membrane.     By  Dr.  Edward  Rind- 
fleisch 725 

E. — Observations  on  the  State  of  the  Liver  in  Infantile  Entero- 
colitis   726 

F. — Cases  of  Intussusception 728 

In  the  Small  Intestines — Intussusception  of  Ileum  into  Colon — Invagi- 
nation of  the  Coecum,  Ileum  and  Ccecum,  or  Ileum,  Coecum,  and  Colon 
— Uncertain. 


DISEASES  OF  CHILDREN. 


PART   I. 


CHAPTER    I. 

INFANCY  AND  CHILDHOOD. 

Infancy  and  childhood  are  in  certain  respects  the  most  important 
and  interesting  periods  of  life.  To  the  physiologist  they  are  espe- 
cially interesting,  because  they  are  the  periods  of  development  and 
of  greatest  functional  activity ;  to  the  pathologist,  because  in  them 
many  diseases  occur  which  are  rarely  or  never  observed  in  the 
other  periods,  or  which  present  in  these  periods  peculiar  features; 
to  the  physician  and  vital  statistician,  because  in  them  there  is  the 
greatest  amount  of  sickness,  and  largest  number  of  deaths. 

Infancy  extends  from  birth  to  the  age  of  two  and  a  half  3^ears, 
or  till  the  completion  of  first  dentition.  In  infancy  the  organs  are 
delicately  organized,  containing  a  large  proportion  of  water,  and 
hence  are  easily  injured.  In  this  period  the  brain  is  rapidly  de- 
veloped— more  so  than  any  other  organ ;  animal  matter  predomi- 
nates in  the  bones;  the  arteries  are  relatively  large,  the  muscles 
small;  the  superficial  veins  are  small.  Fat  is  absent  from  the 
interior  of  the  body,  but  abundant,  in  well-nourished  infants, 
underneath  the  integument.  The  skin  is  delicate,  and  its  temper- 
ature not  much  below  that  of  the  blood.  At  birth  it  has  a  red- 
dish hue,  and  is  covered  with  soft  fine  hairs  (lanugo).  The  reddish 
hue  gradually  fades  into  the  healthy  tint  of  infancy,  and  the  hairs 
fall  out.  In  the  first  two  months  the  sweat  glands  have  little 
functional  activity,  sensible  perspiration  being  quite  rare.  Subse- 
quently i^erspiration  is  freer,  and  in  certain  diseased  states  is 
abundant  (rachitis,  etc.).  The  sebaceous  glands  in  the  first  half 
of  infancy  are  active,  particularly  upon  the  scalp,  producing  often 
2 


18  INFANCY    AND    CHILDHOOD. 

a  pale  yellow  incrustation,  consisting  of  sebaceous  matter  and  epi- 
dermic cells. 

The  secretions  from  the  mucous  surfaces  commence  at  an  early 
period.  At  birth  the  surface  of  the  digestive  tube  is  covered  with 
more  or  less  mucus,  often  in  considerable  quantity.  The  meconium 
is  not  considered,  as  formerly,  to  be  a  product  of  intestinal  secre- 
tion. It  consists  of  flat  epithelial  cells,  fine  hairs,  oil  globules, 
crystals  of  cholesterine,  and  brownish  or  yellowish  masses  of  color- 
ing matter,  probably  from  the  liver.  It  is  supposed  that,  with  the 
exception  of  the  coloring  matter,  the  meconium  is  derived  mainly 
from  the  amniotic  fluid  which  the  foetus  has  swallowed. 

The  most  wonderful  change  occurring  in  the  system  at  birth, 
through  the  exigencies  of  the  new  life,  is  that  in  the  circulation. 
The  flow  of  blood  being  interrupted,  thrombi  form  in  the  umbilical 
vein,  and  arteries,  and  in  the  ductus  arteriosus,  and  ductus  venosus, 
and  these  vessels  gradually  atrophy,  becoming  finally  shrivelled 
but  permanent  cords.  I  have  many  times  at  autopsies  removed 
the  plug  from  the  ductus  arteriosus  when  death  had  occurred  as 
late  as  the  third  week.  The  foramen  ovale  closes  slowly.  I  have 
ordinarily  found  it  open  till  near  the  end  of  the  first  half  year,  but 
the  valve  closes  fully  the  aperture,  so  that  there  is  no  detriment  to 
the  circulation.  Both  the  pulse  and  respiration  are  more  frequent 
during  infancy  than  childhood,  and  are  more  readily  accelerated  by 
moral  and  physical  causes. 

The  stomach  is  less  elongated,  and  emesis  more  readily  produced 
than  in  the  adult.  The  liver  is  large,  occupying  at  birth  nearly 
half  of  the  abdominal  cavity,  but  growing  smaller  in  successive 
months.  The  appetite  is  good  and  digestion  active,  so  that  hunger 
when  appeased,  soon  returns.  The  thymus  gland,  at  birth  about 
the  size  of  an  unexpanded  lung,  slowly  atrophies,  but  it  does  not 
totally  disappear  till  after  infancy. 

The  kidneys,  distinctly  lobulated  at  birth,  gradually  change  their 
form,  so  as  to  present  in  the  last  part  of  infancy  nearly  the  shape 
of  the  organ  in  the  adult.  The  renal  secretion  commences  early, 
even  before  birth.  The  kidneys  seldom  undergo  degenerative 
changes  as  in  the  adult,  but  they  are  liable  to  congestions  and  in- 
flammations. During  the  first  month,  and  especially  the  first  fort- 
night, crystals  of  uric  acid,  and  the  urates,  are  often  found  in  the 
urine,  in  a  state  of  apparent  health,  causing  more  or  less  fretfulness 
in  their  elimination,  staining  the  diaper,  and  not  infrequently 
being  arrested  in  the  tubules  of  the  pyramids,  where  they  can  be 
seen  as  pink-colored  spots  or  lines  (uric  acid  infarction).     These 


CHILDHOOD.  19 

deposits  of  uric  acid  and  the  urates  may  even  occur  in  the  foetus, 
producing  obstruction  and  inflammation  of  the  renal  tubes.  Con- 
genital cystic  degeneration  of  the  kidneys  is,  in  the  opinion  of 
Virchow,  due  to  them.  In  early  infancy  the  senses  are  imperfectly 
developed,  the  eyes  being  attracted  only  by  bright  objects,  and  the 
sense  of  hearing  affected  only  by  loud  noises.  Sleep  is  the  normal 
state  in  the  first  weeks  of  life ;  as  the  age  of  the  infant  advances, 
less  and  less  sleep  is  required ;  but  the  oldest  infants  need  more  than 
children,  and  several  hours  more  than  adults. 

The  new-born  infant  is  apparently  destitute  of  mental  faculties. 
It  seeks  the  breast  by  instinct,  and  it  exhibits  no  jDerception  or 
reflection.  The  loud  cries  with  which  it  commences  its  existence 
are  not  from  anger  or  sufl:ering ;  they  appear  to  be  normal,  like  the 
act  of  nursing,  and  providentially  designed  in  order  to  expand  the 
lungs.  It  is  not  till  the  close,  or  near  the  close,  of  the  first  month, 
that  the  gray  substance  of  the  brain  begins  to  appear — the  probable 
seat  of  the  mind,  and  the  source  of  all  mental  phenomena.  Per- 
ception and  curiosity  are  early  manifested.  The  infant,  as  Edmund 
Burke  has  remarked,  is  constantly  seeking  new  objects  for  its 
amusement,  rejecting  old  playthings  for  such  as  possess  more 
novelty.  Heflection,  a  higher  faculty  of  the  mind,  appears  at  a 
later  period.  The  mind  and  the  bodily  organs  in  infancy  are,  in  a 
high  degree,  impressionable.  Anger  is  excited  by  trivial  causes, 
but  is  easily  appeased ;  and  the  various  functions  in  the  system  are 
disturbed  by  agencies  which  in  youth  or  manhood  would  have  no 
appreciable  eftect. 

Childhood  extends  from  infancy  to  the  age  of  fifteen  years  or 
puberty.  It  is  a  period  of  great  physical  activity,  and  of  rapid 
growth.  The  functions  of  the  various  organs  are  performed  with 
more  moderation  than  in  infancy,  and  are  less  frequently  deranged. 
The  volume  of  the  brain  continues  to  increase  rapidly,  and  it  be- 
comes firmer  than  in  infancy.  It  is  estimated  that  by  the  seventh 
year  the  weight  of  this  organ  has  doubled.  The  mind  now  exerts 
a  controlling  infiuence  over  the  actions  of  the  individual.  The 
digestive  organs  have  changed,  so  that  solid  food  is  required. 
Most  of  the  glandular  organs  are  less  active  than  in  the  greater 
part  of  infancy,  and  some  of  them,  as  the  liver,  are  relatively  smaller. 
Tlie  pulse  and  respiration  gradually  become  less  frequent  as  the 
child  advances  in  age. 


N^'' 


\ 


V 


20        CARE  OF  THE  MOTHER  IN  PREGNANCY. 


CHAPTER  II. 

CARE  OF  THE  MOTHER  IN  PREGNANCY. 

The  frequency  of  miscarriages  and  still-births,  and  the  large 
number  of  ill-formed  and  puny  infants,  born  to  a  precarious  and 
short  existence,  render  imperative,  on  the  part  of  the  mother,  a 
strict  observance  of  the  laws  of  health,  and  an  avoidance  of  all 
exciting  or  perturbating  influences  during  the  time  when  the  foetus 
is  being  developed.  The  diet  should  be  plain  and  easily  digested, 
but  nutritious.  There  is  often  a  craving  in  pregnancy  for  unusual 
articles  of  food.  These  may  sometimes  be  allowed  within  certain 
limits,  provided  they  are  such  as  do  not  derange  the  stomach. 
Meats  and  animal  broths,  together  with  vegetables  and  farinaceous 
food,  should  constitute  the  ordinary  diet,  and  should  be  taken  at 
reo:ular  intervals. 

Daily  exercise,  never  violent,  but  moderate  and  gentle,  is  re- 
quisite. ISTo  exercise  is  better,  none  safer  and  more  likely  to  con- 
tribute to  cheerfulness  and  healthy  functional  activity  of  the 
organs,  than  the  ordinary  household  duties.  Lifting  heavy  weights, 
or  work  which,  like  washing  and  ironing,  causes  great  and  con- 
tinued action  of  the  abdominal  muscles,  should  be  avoided.  Such 
exercise  is  highly  injurious,  and  is  apt  to  produce  premature  labor. 
Exercise  in  the  open  air,  on  foot  or  by  an  easy  conveyance,  con- 
duces to  the  health  of  the  mother,  and  the  growth  and  develop- 
ment of  the  foetus.  On  the  other  hand,  rapid  riding  over  rough 
roads  is  one  of  the  most  dangerous  modes  of  exercise.  It  has  been 
known  to  destroy  the  foetus,  which  up  to  that  time  had  been  appa-  v\ 
rently  vigorous.  "When  such  a  result  occurs,  there  is  probably  v  /, 
more  or  less  detachment  of  the  placenta.  ^  \ '  ■ 

It  being  a  matter  of  the  utmost  importance  that  the  health  of 
the  mother  should  continue  good  during  gestation,  any  disease  ^ 
which  she  may  have  in  this  period,  and  which  afi'ects  her  nutrition 
or  the  character  of  her  blood,  should  be  promptly  cured  if  practi- 
cable, and  with  the  least  possible  reduction  of  the  vital  powers. 
Intermittent  fever,  occurring  during  gestation,  should  never  be 
allowed  to  continue.     It  seriously  retards  foetal  development,  and 


MATERNAL    IMPRESSIONS.  21 

may  produce  miscarriage.  Unless  it  is  controlled  by  proper 
measures,  the  offspring,  though  born  at  term,  is  puny  and  emaci- 
ated. Syphilis,  in  the  pregnant  woman,  also  requires  treatment. 
This  disease,  readily  transmitted  from  the  mother  to  the  fcotus 
through  the  ovum  or  the  uterine  circulation,  may  be  eradicated  by 
anti-syphilitic  treatment  of  the  mother,  or  at  least  so  modified  that 
the  infant  is  born  vigorous  and  healthy. 

The  pregnant  woman  should  avoid  all  causes  of  undue  mental 
excitement.  This  is  almost  as  necessary  as  the  avoidance  of  great 
physical  exertiofi.  There  is,  during  pregnancy,  unusual  suscep- 
tibility to  mental  impressions,  and  this  should  be  borne  in  mind 
not  only  by  the  woman  herself,  but  by  those  who  associate  with 
her. 

Strong  emotions,  whether  of  joy,  sorrow,  or  anger,  affect  pri- 
marily the  nervous  system,  but  indirectly  most  of  the  organs  of 
the  body.  Observations  have  long  established  the  fact,  that  such 
emotions  influence  the  state  and  functions  not  only  of  the  digestive 
and  glandular,  but  muscular  organs,  as  the  heart  and  uterus. 
Physicians  are  familiar  with  cases  in  which  vivid  mental  impres- 
sions produced  uterine  contractions,  and  even  miscarriage,  or  have 
disturbed  the  catamenial  function.  Therefore,  the  associations  and 
cares  of  pregnant  women  should  be  such  as  conduce  to  cheerfulness 
and  equanimity. 

It  is  the  popular  belief,  and  the  belief  of  many  physicians,  that 
vivid  mental  impressions  sometimes  have  a  direct  effect  on  the  de- 
velopment of  the  foetus.  Many  cases  are  on  record  in  which  infants 
were  born  with  marks  or  deformities,  corresponding  in  character 
with  objects  which  had  been  seen  and  had  made  a  strong  impres- 
sion on  the  maternal  mind  at  some  period  of  gestation.  Whether 
the  mind  of  the  mother  exerts  a  controlling  influence  on  the  form 
and  color  of  the  foetus,  is  a  subject  of  great  interest  to  the  psycho- 
logist as  well  as  physiologist  and  physician,  since  it  involves  no 
less  a  question  than  the  power  and  scope  of  the  human  mind. 
Violent  emotions,  it  is  admitted,  may  aflfect  directly  most  of  the 
important  organs  in  the  system.  They  may  derange  the  liver, 
causing  jaundice,  accelerate,  or  for  a  moment  suspend  the  heart's 
action,  stimulate  the  kidneys,  causing  diuresis,  or  even  the  intes- 
tinal follicles,  causing  watery  evacuations.  But  with  all  these 
organs  the  ])rain  is  connected  by  nerves  which  anatomy  reveals. 
On  the  other  hand,  the  mother  and  foetus  have  a  distinct  existence 
as  regards  their  nervous  systems,  and  even  their  blood.  Still,  the 
multitude  of  facts  which  have  accumulated  justify  the  belief  that 


22        CARE  OF  THE  MOTHER  IN  PREGNANCY. 

deformity  or  other  abnormal  development  of  the  foetus  is,  some- 
times, due  to  the  emotions  of  the  mother.  Some  of  the  eases 
related  by  Dr.  Whitehead,  in  his  work  on  hereditary  diseases,  are 
very  striking  and  difficult  to  explain,  on  the  ground  of  coincidence. 
I  have  met  the  following  cases.  An  Irish  woman  of  strong 
emotions  and  superstitions  was  passing  along  a  street  in  the  first 
months  of  her  gestation,  when  she  was  accosted  by  a  beggar,  who 
raised  her  hand,  destitute  of  thumb  and  fingers,  and  in  "  God's 
name"  asked  for  alms.  The  woman  passed  on :  but  reflecting  in 
whose  name  money  was  asked,  felt  that  she  had  committed  a  great 
sin  in  refusing  assistance.  She  returned  to  the  place  where  she  had 
met  the  beggar,  and  on  difierent  days,  but  never  afterwards  saw 
her.  Harassed  by  the  thought  of  her  imaginary  sin,  so  that  for 
weeks,  according  to  her  statement,  she  was  made  wretched  by  it, 
she  approached  her  confinement.  A  female  infant  was  born,  other- 
wise perfect,  but  lacking  the  fingers  and  thumb  of  one  hand.  The 
deformed  limb  was  on  the  same  side,  and  it  seemed  to  the  mother 
to  resemble  precisely  that  of  the  beggar.  In  another  case  which  I 
met,  a  very  similar  malformation  was  attributed  by  the  mother  of 
the  child  to  an  accident  occurring  to  a  near  relative,  which  necessi- 
tated amputation  during  the  time  of  her  gestation.  I  examined 
both  of  these  children  with  defective  limbs,  and  have  no  doubt  of 
the  truthfulness  of  the  parents.  In  May,  1868, 1  removed  a  super- 
numerary thumb  from  an  infant,  whose  mother,  a  baker's  wife, 
gave  me  the  following  history:  ISTo  one  of  the  family,  and  no  an- 
cestor, to  her  knowledge,  presented  this  deformity.  In  the  early 
months  of  her  gestation  she  sold  bread  from  the  counter,  and 
nearly  every  day  a  child  with  double  thumb  came  in  for  a  penny 
roll,  presenting  the  penny  between  the  thumb  and  the  finger. 
After  the  third  month  she  left  the  bakery,  but  the  malformation 
was  so  impressed  upon  her  mind,  that  she  was  not  surprised  to  see 
it  reproduced  in  her  infant. 

Professor  William  A.  Hammond,  of  this  city,  in  an  interesting 
paper  on  the  "Influence  of  the  Maternal  Mind,"  etc.  {Quarterly 
Journal  of  Psychological  Medicine^  January,  1868),  says :  "  The  chances 
of  these  instances,  and  others,  which  I  have  mentioned,  being  due 
to  coincidence,  are  infinitesimally  small,  and  though  I  am  careful 
not  to  reason  upon  the  principle  of  post  hoc,  ergo  propter  hoc,  I 
cannot,  nor  do  I  think  any  other  person  can,  no  matter  how  logical 
may  be  his  mind,  reason  fairly  against  the  connection  of  cause  and 
effect  in  such  cases.  The  correctness  of  the  facts  can  only  be  ques- 
tioned; if  these  be  accepted,  the  probabilities  are  thousands  of  mil- 


MORTALITY    OF    EARLY    LIFE.  23 

lions  to  one,  that  the  relation  between  the  phenomena  is  direct." 
Professor  Dalton  also  says  {Human  Physiology)^  "there  is  now  little 
room  for  doubt  that  various  deformities  and  deficiencies  of  the 
foetus,  conformably  to  the  popular  belief,  do  really  originate  in 
certain  cases  from  nervous  impressions,  such  as  disgust,  fear,  or 
anger,  experienced  by  the  mother."  The  observations  on  which 
this  belief  is  based  relate  both  to  man  and  the  lower  animals.  A 
very  strong  argument  in  its  support  is,  as  Professor  Hammond 
remarks,  the  popular  opinion,  which  dates  back  to  the  time  of 
Jacob  (Genesis  xxx.).  An  almost  universal  sentiment,  running 
through  centuries,  is  rarely  wholly  fallacious.  It  has  some  truth 
for  its  foundation,  especially  when,  as  in  this  instance,  the  subject 
is  one  of  observation. 

If  maternal  emotions  affect  the  development  of  the  exterior  of 
the  foetus,  as  observations  show,  and  physiologists  admit,  the  pre- 
sumption is  strong,  that  they  may  affect  also  the  proper  develop- 
ment, and  adjustment  of  the  parts  of  the  brain,  an  organ  so  com- 
plex and  delicate,  and  may  therefore  give  rise  to  idiocy.  Dr.  Seguin 
{Idiocy  and  its  Treatment^  etc.,  New  York,  1866)  thus  remarks  on 
this  point:  "Impressions*  will,  sometimes,  reach  the  foetus,  in  its 
recess,  cut  off  its  legs  or  arms,  or  inflict  large  flesh  wounds,  before 
birth,  .  .  .  from  which  we  surmise  that  idiocy  holds  unknown 
though  certain  relations  to  maternal  impressions,  as  modifications 
to  placental  nutrition." 

In  view  of  such  important  facts,  the  duty  of  the  pregnant  woman 
is  rendered  the  more  imperative  to  avoid  the  presence  of  disagree- 
able and  unsightly  objects,  as  well  as  all  causes  of  excitement,  and 
to  remove,  as  soon  as  possible,  vivid  and  unpleasant  impressions, 
by  quiet  diversion  of  the  mind. 


CHAPTER    III. 
MORTALITY  OF  EARLY  LIFE— ITS  CAUSES  AND  PREVENTION. 

No  fact  is  better  known  in  the  profession,  than  that  the  first 
years  of  life  constitute  the  period  of  greatest  mortality. 

In  England,  where  there  is  an  accurate  registration  of  births  and 
deaths,  statistics  show  fifteen  deaths  in  every  hundred  infants  in 
the  first  year  of  life,  and  between  four  and  five  deaths  in  the  first 


24  MORTALITY    OF    EARLY    LIFE. 

month.  Statistics  on  the  continent  correspond  with  those  in  Eng- 
land, as  regards  the  periods  of  greatest  mortality.  Quetelet  says, 
"...  there  die  during  the  first  month  after  birth,  four  times 
as  many  children  as  during  the  second  month  after  birth,  and 
almost  as  many  as  during  the  entirety  of  the  two  years  that  follow 
the  first  year,  although  even  then  the  mortality  is  high.  The 
tables  of  mortality  prove,  in  fact,  that  one-tenth  of  children  born, 
die  before  the  first  month  has  been  completed." 

In  this  country,  in  consequence  of  deficient  registration  of  births, 
the  percentage  of  deaths  to  births  cannot  be  accurately  ascertained. 
In  this  city,  53  per  cent,  of  the  total  number  of  deaths  occur  under 
the  age  of  five  years,  and  26  per  cent,  under  the  age  of  one  year. 
According  to  the  census  of  1865,  there  were  in  ISTew  York  city 
95,020  children  under  the  age  of  five  years,  and  during  the  five 
years  ending  with  1865,  49,000  children  five  years  old  and  under 
had  died.  Therefore,  according  to  these  statistics,  more  than  one- 
third  of  all  the  infants  born  in  this  city  die  under  the  age  of  five 
years.  An  error,  however,  occurs  from  the  fact  that,  while  the 
death  statistics  were  complete,  it  is  known  there  were  more  children 
in  the  city  than  were  embraced  in  the  census  returns.  Still  it  may, 
I  think,  be  safely  stated  that  one-fourth  of  the  children  born  in 
this  city  die  before  the  age  of  five  years. 

In  less  crowded  cities  and  the  rural  districts,  it  is  known  that 
the  percentage  of  deaths  in  the  first  years  of  life  to  the  total  num- 
ber of  deaths  is  considerably  less  than  in  ]!Tew  York  city,  but  it  is 
nevertheless  large. 

As  the  child  advances  towards  puberty,  the  liability  to  sickness 
and  death  gradually  diminishes,  but  even  the  last  years  of  child- 
hood present  a  considerably  larger  percentage  of  deaths  to  the 
population  than  does  youth  or  manhood. 

The  causes  of  this  great  mortality  of  infants  and  children,  and 
the  means  of  diminishing  it,  deserve  careful  consideration. 

Some  of  the  causes  which  conspire  to  produce  this  mortality  are 
in  a  measure  unavoidable.  Such  are  congenital  vices  of  formation 
of  internal  organs.  Many  of  the  internal  malformations  neces- 
sarily occasion  an  early  death.  Cases  of  anencephalus,  most  cases 
of  congenital  hydrocephalus,  of  spina  bifida,  of  cyanosis,  are  fatal 
before  the  close  of  infancy.  These  defects  of  formation  we  cannot 
detect  before  birth,  and  their  causes  are  often  obscure.  Some  of 
them  seem  to  result  from  inflammation,  believed  to  be,  occasionally, 
syphilitic,  develoj)ed  at  some  period  of  foetal  existence.  Other  in- 
ternal malformations  are  attributable  to  perturbating  influences, 


CAUSES    OF    INFANTILE    MORTALITY.  25 

operating  temporarily  on  the  mother  during  gestation.  But  in  a 
large  proportion  of  cases,  we  cannot  assign  the  cause.  Obviously, 
only  partial  success  can  attend  our  efforts,  as  regards  prevention 
in  these  cases,  and  almost  no  success,  as  regards  the  use  of  remedial 
measures. 

Another  obvious  cause  of  the  great  mortality  of  early  life,  is 
natural  feebleness  of  system,  especially  in  infancy.  The  younger 
the  patient,  prior  to  the  middle  period  of  life,  the  sooner  are  the 
vital  powers  exhausted  by  disease.  Hence  a  larger  proportion  of 
infants  succumb  to  the  same  malady  than  children,  and  a  larger 
proportion  of  children  than  adults.  This  statement  is  true  of  in- 
fancy and  childhood  in  general.  It  is  a  law  in  nature,  and  cannot 
be  changed  by  art.  But  there  are  many  infants  born  with  heredi- 
tary disease,  or  a  strong  predisposition  to  disease,  through  a  fault, 
which  is,  in  a  degree,  remediable,  in  the  system  of  one  or  Ijoth 
parents,  as,  for  example,  the  syphilitic,  scrofulous,  or  tubercular 
diathesis.  Parents  seriously  affected  by  such  diseases  cannot,  with- 
out corrective  treatment,  have  healthy  offspring.  Their  children 
are  among  the  first  to  droop  and  die,  either  directly  from  the 
inherited  disease,  or  from  feebleness  of  constitution,  which  such 
disease  entails,  and  which  renders  them  an  easy  prey  to  other  dis- 
eases. The  duty  of  the  physician,  as  regards  such  parents,  is  obvi- 
ous. He  may,  by  therapeutic  and  hygienic  measures,  secure  a  more 
healthy  progeny,  and,  so  far  as  he  can  do  this,  he  aids  in  diminish- 
ing the  infantile  mortality.  He  may  sometimes,  by  timely  mea- 
sures directed  to  the  infant,  establish  a  better  state  of  health. 

The  subject  of  hereditary  disease  is  one  of  great  interest  and 
importance,  especially  as  regards  the  city  population.  Inherited 
affections  are  less  common  in  the  country,  but  in  the  city  they  con- 
tribute largely  to  the  number  of  deaths  in  early  life. 

Another  important  cause  of  the  great  mortality  of  infants  and 
children,  is  the  fact  that  they  are  peculiarly  liable  to  certain  severe 
and  fatal  diseases.  The  zymotic  diseases,  which,  as  a  rule,  occur 
but  once,  are  more  common  at  this  age  than  subsequently.  Some 
of  these,  as  scarlet  fever,  greatly  increase  the  number  of  deaths. 
The  zymotic  diseases  are  for  the  most  part  infectious.  Hence  they 
are  very  prevalent  and  fatal  in  cities,  where  there  is  much  greater 
intercourse  of  children  than  in  the  country.  Scarlet  fever  is  one 
of  the  six  most  fatal  diseases  in  ISTew  York  city.  The  prevention 
of  contagious  diseases  obviously  depends,  in  great  measure,  on 
isolation,  which  it  is  the  duty  of  the  physician  to  advise.  Boards 
of  health,  or  civil  authorities,  may  also  do  something  as  regards 


26  MORTALITY    OF    EARLY    LIFE. 

the  scliools,  to  prevent  the  spread  of  these  diseases.  One  of  them, 
the  most  loathsome  and  dreaded  of  all,  namely,  smallpox,  the  phy- 
sician has  the  power  to  prevent.  Some  of  the  most  fatal  diseases 
of  life,  not  contagions,  as  croup  and  capillary  bronchitis,  also  occur 
in  infancy  and  childhood,  materially  increasing  the  mortality. 
These  local  affections  cannot  be  prevented  by  the  physician,  but 
only  by  judicious  hygienic  management  on  the  part  of  families. 

Another  obvious  and  important  cause  of  the  mortality  of  early 
life,  is  the  anti-hygienic  condition  or  state  in  which  many  children 
live  in  consequence  of  the  poverty  or  gross  negligence  of  parents. 

Residence  in  insalubrious  localities,  personal  and  domiciliary 
uncleanliness,  exposure  without  proper  protection  to  vicissitudes  of 
weather,  are  fertile  causes  of  sickness  and  death.  Hence  one  reason 
of  the  great  infantile  mortality  among  the  city  poor,  who  live  in 
damp  and  dark  alleys,  and  in  crowded  and  filthy  tenement-houses, 
breathing  night  and  day  an  atmosphere  loaded  with  noxious  gases. 
All  physicians  are  aware  how  the  malignant  diseases,  such  as 
Asiatic  cholera,  cholera  infantum,  diphtheria,  and  typhus  fever, 
seek  the  quarters  of  the  city  poor,  and  what  terrible  havoc  they 
make  there.  All  are  aware,  also,  what  wonderful  recoveries  occur 
when  feeble  and  attenuated  infants,  gradually  sinking  with  chronic 
disease,  induced  in  great  measure  by  this  malaria,  are  transferred 
from  such  localities  to  the  pure  air  of  the  country. 

Careless  management  of  young  children,  as  regards  dress,  in- 
creases greatly  the  liability  to  local  diseases,  such  as  commonly 
occur  from  exposure  to  cold.  These  are  inflammatory  affections, 
seated  chiefly  uj)on  the  mucous  surfaces,  but  sometimes  in  paren- 
chymatous organs.  Adults,  aware  of  the  effect  of  sudden  change 
of  temperature  from  warm  to  cold,  or  of  exposure  to  currents  of 
air,  protect  themselves  by  additional  clothing.  Such  precautionary 
measures  are  often  lacking  in  the  management  of  young  children, 
and  hence  one  cause  of  their  great  liability  to  local  afiections,  both 
of  the  respiratory  and  digestive  organs. 

Routh,  in  his  excellent  treatise  on  Infant  Feeding,  says :  "Among 
the  most  pernicious  influences  to  young  children,  however,  we  may 
include  cold.  The  change  of  temperature  from  45°  to  4°  or  5° 
below  zero,  as  before  stated,  producing  an  increase  of  mortality  in 
London  alone  of  three  to  five  hundred.  As  out  of  one  hundred 
deaths,  however,  from  all  specified  causes,  nearly  twenty-four 
occur  to  children  under  one,  and  thirty-six  to  children  under  five ; 
the  great  increase  of  mortality  to  children  by  cold,  is  thus,  at 
once,  made  obvious.     Indeed,  it  is  a  household  word  amongst  us, 


IMPROPER    FEEDING.  27 

which  takes  its  origin  from  the  Registrar-General's  returns,  that  a 
very  cold  week  always  increases  the  mortality  of  the  very  young 
and  the  very  aged." 

Lastly,  a  very  important  cause  of  mortality  in  early  life  is  the 
use  of  improper  food.  In  infants,  artificial  feeding  in  place  of 
the  aliment  which  nature  has  provided  for  them,  and,  in  children, 
the  use  of  innutritions  or  indigestible  articles  of  diet,  give  rise  to 
diarrhoeal  maladies,  emaciation,  and  death  in  numerous  instances. 
Sometimes,  also,  defective  alimentation  is  the  cause  of  scrofulous 
or  tuberculous  ailments,  and  sometimes  it  gives  rise  to  a  cachexia 
or  feebleness  of  system,  which,  without  engendering  any  positive 
disease,  renders  those  thus  affected  less  able  to  support  disease 
induced  by  other  causes.  A  committee,  of  which  Prof.  Austin 
Flint,  Jr.,  was  chairman,  appointed  in  1867  to  revise  the  "dietary 
table  of  the  Children's  Nurseries  on  Randall's  Island,"  state,  with 
much  truth  and  force :  "  Children  ....  are  not  capable  of  resist- 
ing bad  alimentation,  either  as  regards  quantity,  quality,  or  variety. 
At  that  age  the  demands  of  the  system  for  nourishment  are  in 
excess  of  the  waste ;  the  extra  quantity  being  required  for  growth 
and  development.  If  the  proper  quantity  and  variety  of  food  be 
not  provided,  full  development  cannot  take  place,  and  the  children 
grow  up,  if  they  survive,  into  puny  men  and  women,  incapable  of 
the  ordinary  amount  of  labor,  and  liable  to  diseases  of  various 
kinds.  This  is  frequently  illustrated  in  the  higher  walks  of  life, 
particularly  in  females ;  for  many  suffer  through  life  from  improper 
diet  in  boarding-schools,  due  to  false  and  artificial  notions  of  deli- 
cacy or  refinement.  After  a  certain  period  of  improper  and  de- 
ficient diet  in  children,  the  appetite  becomes  permanently  impaired, 
and  the  system  is  rendered  incapable  of  appropriating  the  amount 
of  matter  necessary  to  proper  development  and  growth." 

Improper  feeding,  like  other  causes  of  mortality,  is  much  more 
injurious,  much  more  frequently  the  cause  of  death,  in  the  city  than 
country.  Statistics  in  Europe,  as  well  as  this  side  of  the  Atlantic, 
establish  this  fact.  It  is  in  infancy,  and  especially  in  the  first  year, 
that  the  use  of  unwholesome  food  entails  the  most  serious  conse- 
quences. 'No  artificially  prepared  food  is  a  good  substitute  for  the 
mother's  milk,  and  hence  artificial  feeding  of  the  infant,  unless 
under  the  most  favorable  circumstances,  results  disastrously.  In 
the  country,  where  salubrious  air  and  sunlight  conspire  to  invigo- 
rate the  system,  and  a  robust  constitution  is  inherited,  and  where 
cow's  milk  fresh  and  of  the  best  quality  is  readily  obtained,  lacta- 


28  LACTATION. 

tion  is  not  so  necessary  for  the  well-being  of  the  infant ;  but  in  the 
city  its  importance  cannot  be  too  strongly  urged. 

The  foundlings  of  the  cities  afibrd  the  most  striking  and  con- 
vincing proofs  of  the  advantage  of  lactation.  In  some  cities  found- 
lings are  wet-nursed,  while  in  others  they  are  dry-nursed,  and  the 
result  is  always  greatly  in  favor  of  the  former.  Thus,  on  the 
continent,  in  Lyons  and  Parthenay,  where  foundlings  are  wet- 
nursed  almost  from  the  time  that  they  are  received,  the  deaths  are 
33.7  and  85  per  cent.  On  the  other  hand,  in  Paris,  Rheims,  and 
Aix,  where  the  foundlings  are  wholly  dry-nursed,  their  deaths  are 
50.3,  63.9,  and  80  per  cent. 

In  this  city  the  foundlings,  amounting  to  several  hundred  a  year, 
were,  till  recently,  dry-nursed ;  and,  incredible  as  it  may  appear, 
their  mortality,  with  this  mode  of  alimentation,  nearly  reached 
100  per  cent.  Recently  wet-nurses  have  been  employed,  for  a  part 
of  the  foundlings,  with  a  much  more  favorable  result. 

These  facts,  to  which  others  might  be  added  from  the  experience 
of  European  cities,  show  the  importance  of  lactation  as  a  means 
of  reducing  infantile  mortality  in  the  cities.  "What  has  been  stated 
as  regards  the  result  of  artificial  feeding  of  foundlings,  is  true,  in 
great  measure,  in  reference  to  all  city  infants.  The  ill  efiect  of 
artificial  feeding  is  well  known  in  this  city,  and  it  is  the  common 
practice  in  families  to  employ  a  hired  wet-nurse,  if,  for  any  reason, 
the  mother's  milk  is  insufficient. 

When  the  infant  has  reached  the  age  at  which  it  is  proper  to 
wean  it,  the  digestive  organs  are  less  frequently  deranged  by  errors 
of  diet.  More  substantial  food,  and  considerable  variety  in  it,  may 
now  be  not  only  safely  allowed,  but  are  required  by  the  wants  of 
the  system.  Still,  the  feeding  of  children  in  health,  and  much 
more  in  sickness,  is  a  subject  of  great  importance.  Therefore  lac- 
tation, and  the  diet  of  infancy  and  childhood,  will  occupy  our 
attention  in  the  following  pages. 


CHAPTER   IV. 

LACTATION. 

It  is  desirable  that  the  infant,  as  soon  as  it  requires  nutriment, 
should  receive  breast  milk.  If  it  is  fed,  for  a  few  days,  with  the 
bottle  or  spoon,  it  may  be  difficult  finally  to  induce  it  to  take  the 


HINDRANCES    TO    LACTATION.  29 

breast;  therefore  it  is  well  to  determine  early  whether  the  mother 
will  be  able  to  wet-nurse  her  infant,  so  that,  if  unable,  suitable 
provision  may  be  made. 

The  matter  of  determining,  beforehand,  the  capability  of  the 
mother  for  w'et-nursing  has  been  investigated  by  Dr.  Donnd,  of 
Paris,  and  in  his  treatise  on  Mothers  and  Infants  he  describes  the 
mode  in  which  it  may  be  ascertained.  The  desired  information,  in 
his  opinion,  may  be  acquired  by  examining  the  colostrum,  which 
is  secreted  in  small  quantity,  in  the  last  months  of  gestation,  and 
which  can  be  squeezed  from  the  breast  in  sufficient  quantity  for 
inspection. 

In  some  women,  according  to  Dr.  Donn^,  the  colostrum  is  so 
scanty  that  only  a  drop,  or  half  a  drop,  can  be  obtained  from  the 
nipple  by  careful  pressure.  This  will  be  found  by  the  microscope 
to  contain  but  few  milk  globules,  ill-formed,  and  a  few  granular 
bodies,  such  as  the  colostrum  ordinarily  contains.  Such  women 
almost  invariably  furnish  poor  milk,  and  in  small  quantity.  In 
other  women  the  colostrum  is  abundant,  but  thin,  resembling  gum- 
water  ;  it  lacks  the  yellow  streaks  and  viscous  character  of  ordinary 
colostrum,  and  it  flows  readily  from  the  nipple.  The  milk  of  such 
w^omen  is  sometimes  scanty,  sometimes  abundant,  but  it  is  watery 
and  deficient  in  nutritive  principles.  In  a  third  class  of  women, 
the  colostrum  is  pretty  abundant,  and  it  contains  yellowish  streaks, 
of  more  or  less  consistence,  which  are  found  to  be  rich  in  milk 
globules,  of  good  size,  and  without  the  admixture  of  mucous  glo- 
bules. "Women  furnishing  such  colostrum  in  the  last  weeks  of 
gestation  will  have  sufficient  milk,  and  of  good  quality.  These 
latter  women  make  the  best  wet-nurses. 


Hindrances  to  Lactation  and  Physical  Conditions  Rendering  it  Improper. 

The  primipara  often  experiences  difficulty  in  wet-nursing  in  con- 
sequence of  a  depressed  state  of  the  nipple.  It  is  not  sufficiently 
prominent  to  be  readily  grasped  by  the  mouth,  and  after  inefiectual 
attempts  the  infant  becomes  fretful  when  applied  to  the  breast  and, 
perhaps,  for  a  time  refuses  it  altogether.  Multiparas  occasionally 
experience  the  same  inconvenience,  but  it  is  not  common  when 
there  has  once  been  successful  lactation.  By  calmness  and  perse- 
verance on  the  part  of  the  mother,  the  infant  can  usually  be  made 
to  seize  the  nipple  in  the  course  of  a  week. 

Depression  of  the  nipple  is,  to  a  certain  extent,  the  result  of 
pressure  upon  it  by  the  dress  during  gestation.     The  state  of  the 


80  LACTATION". 

nipples  should,  indeed,  in  those  who  have  never  suckled,  receive 
early  attention,  even  before  the  birth  of  the  infant.  Tightness  of 
dress  around  the  breast,  as  indeed  upon  every  part  of  the  body, 
should  be  avoided,  and  from  time  to  time  gentle  traction  should 
be  made  upon  the  nipple,  if  it  is  depressed.  It  may  be  drawn  out 
by  the  fingers  of  the  mother  several  times  each  day,  or  by  a  com- 
mon breast-pump,  or  by  suction  with  a  tobacco-pipe,  the  edge  of 
the  bowl  having  been  smoothed.  Occasionally,  in  these  cases  of 
deficient  nipple,  the  mother,  fatigued  and  discouraged  by  her  fre- 
quent ineffectual  attempts  to  induce  the  infant  to  nurse,  becomes 
feverish  and  excited,  so  that  the  quantity  of  her  milk  is  sensibly 
diminished.  The  physician  should  assure  her,  as  he  usually  can 
with  confidence,  that  in  a  few  days,  as  the  baby  becomes  a  little 
stronger,  there  will  be  no  difficulty  in  its  nursing.  Some  women 
are  unremitting  in  their  endeavors  to  procure  nursing.  This  should 
be  forbidden,  since  the  lack  of  sleep,  and  the  nervousness  which 
such  constant  attention  produces,  tend  to  defeat  the  object  which 
they  have  in  view,  by  diminishing  the  secretion  of  milk.  The 
application  of  the  infant  to  the  breast  once  in  an  hour  and  a  half 
to  two  hours  is  quite  sufficient.  In  some  cases,  when  practicable, 
the  aid  of  another  woman,  whose  infant  is  a  little  older,  is  in- 
valuable. The  exchange  of  infants  for  a  few  times  may  remedy 
the  difficulty. 

Occasionally  lactation  is  rendered  difficult  and  painful  by  too 
long  delay  before  applying  the  infant  to  the  breast.  "When  the 
mother  has  rested  a  few  hours  after  her  confinement,  from  three  to 
six  in  ordinary  cases,  lactation  may  commence.  There  is,  at  first, 
but  very  little  milk,  often  only  a  few  drops,  but  the  secretion  is 
promoted  by  nursing,  so  that  the  requisite  amount  is  sooner  ob- 
tained than  when  the  infant  is  kept  from  the  breast  till  the  second 
or  third  day.  If,  as  some  j)hysicians  advise,  suckling  is  deferred 
till  the  breasts  are  full  and  tender,  and  if,  as  is  often  the  case  with 
primiparse,  the  nipples  are  also  tender,  many  mothers  lack  the  for- 
titude required  to  allow  their  infants  to  obtain  a  sufficient  amount 
of  milk.  Excoriated  and  fissured  nipples  constitute  a  serious  im- 
pediment to  lactation.  They  are  very  sensitive  on  pressure,  and 
are  long  in  healing.  They  are  fully  described  in  works  which 
relate  to  female  diseases,  and  their  treatment  pointed  out.  Occa- 
sionally fissured  nipples  do  harm  to  the  infant  by  the  blood  which 
escaf»es  and  is  swallowed  with  the  milk.  A  case  is  related  in 
which  positive  indigestion  was  caused  in  this  way,  the  infant 
vomiting,  after  each  nursing,  milk  mixed  with  blood.     The  local 


HINDRANCES    TO    LACTATION.  31 

hindrances  to  lactation  described  above  can,  in  most  instances,  be 
relieved  in  the  course  of  a  few  weeks. 

There  is,  occasionally,  a  constitutional  state  of  the  mother  which 
necessitates  either  the  employment  of  a  hired  wet-nurse  or  wean- 
ing. This  is  the  case  when  there  is  a  strong  tendency  to  tubercu- 
losis. If  the  complexion  is  pallid,  and  the  system  at  all  emaciated, 
and  suckling  is  attended  by  more  or  less  exhaustion,  and  if  with 
fair  trial  of  wine  and  tonics  there  is  no  improvement,  the  physician 
is  justified  in  forbidding  farther  attempts  at  wet-nursing.  If  there 
is,  under  such  circumstances,  an  hereditary  tendency  to  tubercu- 
losis, it  is  his  duty  to  interdict  it  positively.  The  opinion  of  the 
physician,  in  such  a  matter,  should  be  formed  after  mature  delibe- 
ration. There  are  many  women  who,  suflering  temporarily  from 
depression,  and  discouraged,  are  ready  at  once  to  abandon  their 
infants  to  the  care  of  others,  with  the  least  encouragement  on  the 
part  of  the  physician  to  do  so,  but  who,  by  attention  to  their  own 
health,  and  especially  by  taking  more  sleep,  soon  recover  from  their 
depression  and  become  good  wet-nurses.  On  the  other  hand,  night- 
sweats,  a  cough,  and  progressive  decline  in  health,  show  the  need 
of  immediate  suspension  of  wet-nursing. 

Sometimes  women,  prior  to  pregnancy,  present  indubitable  evi- 
dence of  tuberculosis,  but  by  the  imx^roved  general  health  which 
attends  pregnancy,  the  disease  is  temporarily  arrested.  Such 
women  should  never  suckle  their  infants.  If  they  do,  they  soon 
lose  all  that  was  gained,  and  the  disease  advances  rapidly.  These 
objections  to  wet-nursing  in  such  a  state  of  health  apply  to  the 
mother.  There  are  also  objections  as  regards  the  infant.  The  milk 
of  those  in  decidedly  infirm  health,  is  deficient  in  nutritive  prin- 
cij^les.  Their  infants,  therefore,  are  ill-nourished,  and,  if  they 
have  inherited  a  predisposition  to  tuberculosis,  there  is  great  danger 
that  this  disease  will  be  developed  in  them ;  whereas  with  healthy 
wet-nursing,  even  a  strong  predisposition  may  remain  latent.  M. 
Donne  relates  the  following  instructive  cases,  which  show  the 
danger  which  sometimes  attends  suckling,  and  the  imperative  ne- 
cessity which  may  arise  of  discontinuing  it.  "A  very  light-com- 
plexioned  young  mother,  in  very  good  health,  and  of  a  good  con- 
stitution, though  somewhat  delicate,  was  nursing  for  the  third 
time,  and  as  regarded  the  child  successfully.  All  at  once  this 
young  woman  experienced  a  feeling  of  exhaustion.  Her  skin  be- 
came constantly  hot ;  there  were  cough,  oppression,  night-sweats ; 
her  strength  visibly  declined,  and  in  less  than  a  fortnight  she  pre- 
sented the  ordinary  symptoms  of  consumption.     The  nursing  was 


32  .  LACTATION. 

immediately  abandoned,  and  from  the  moment  the  secretion  of 
milk  had  ceased,  all  the  troubles  disappeared."  "A  woman  of 
forty  years  of  age  .  .  .  having  lost,  one  after  another,  several 
children,  all  of  whom  she  had  put  out  to  nurse,  determined  to 
nurse  the  last  one  herself.  .  .  .  This  woman,  being  vigorous 
and  well-built,  was  eager  for  the  work,  and,  filled  with  devotion 
and  spirit,  she  gave  herself  up  to  the  nursing  of  her  child  with  a 
sort  of  fury.  At  nine  months,  she  still  nursed  him  from  fifteen  to 
twenty  times  a  day.  Having  become  extremely  emaciated,  she 
fell  all  at  once  into  a  state  of  weakness,  from  which  nothing  could 
raise  her,  and  two  days  after  the  poor  woman  died  of  exhaustion."' 

Constitutional  syphilis  in  the  mother  does  not  contra-indicate 
lactation.  It  is  probable  that  the  infant  also  has  it.  The  mother 
should  take  anti-syphilitic  remedies,  which  will  eradicate  the  dis- 
ease in  herself,  and  also,  if  it  be  present,  in  the  infant.  Febrile 
affections,  also,  do  not  in  general  contra-indicate  lactation.  They 
may,  however,  for  a  time,  diminish  the  quantity  of  milk,  or  impair 
its  quality.  If,  however,  the  mother  is  in  a  critical  state,  or  much 
reduced,  whatever  the  disease,  suckling  should  cease.  Whether 
or  not  the  infant  should  be  taken  from  the  breast,  if  the  mother  is 
sufifering  from  one  of  the  essential  fevers,  depends  on  the  degree 
of  her  exhaustion.  Twice  I  have  known  newly-born  infants  nurse 
their  mothers  through  attacks  of  scarlet  fever,  without  contracting 
it,  but  suffering  immediately  afterwards  from  severe  and  protracted 
eczema.  In  the  country,  where  artificially-fed  infants  as  a  rule 
do  well,  it  might  be  best  to  wean  if  the  mother  is  affected  with 
such  a  disease,  but  in  the  city  eczema  is  less  dangerous  than  the 
diarrhoeal  aflJections,  which  early  weaning  is  apt  to  entail.  In  most 
cases  of  typhus  or  typhoid,  weaning  or  procuring  a  wet-nurse  is 
necessary,  on  account  of  the  depression  of  the  vital  powers  which 
this  disease  produces. 

Inflammatory  affections,  unless  of  a  dangerous  character,  do  not 
ordinarily  interfere  with  lactation,  except  that  the  quantity  of 
milk  may  be  somewhat  diminished.  In  severe  inflammation,  it 
may  be  so  necessary  to  husband  the  strength,  or  to  keep  the  patient 
perfectly  quiet,  that  suckling  her  infant  would  be  injudicious.     It 

'  A  very  similar  case  recently  occurred  in  my  practice.  A  young  and  healthy 
woman  from  the  country,  suckling  her  second  infant,  on  coming  to  the  city,  lived 
in  a  dark  and  very  imperfectly  ventilated  room,  on  the  first  floor,  and  in  the  rear  of 
a  crowded  tenement-house.  She  soon  lost  her  appetite,  but  continued  suckling  for 
three  months,  when  she  became  so  ansemic  and  feeble  that  she  was  compelled  to 
seek  medical  advice.  She  died  without  local  disease,  notwithstanding  the  most 
nutritious  diet  and  the  free  use  of  stimulants  and  tonics. 


FACTS  AND  RULES  IN  REFERENCE  TO  LACTATION.   33 

should  then  be  transferred  to  a  wet-nurse  or  weaned.  Inflamma- 
tion of  tlie  breast  often  presents  an  impediment  to  lactation.  It  is 
a  common  and  painful  aliection,  suspending,  or  greatly  diminish- 
ing the  secretion  of  milk  in  the  affected  gland.  Nursing  should 
cease  as  soon  as  there  are  evident  signs  of  inflammation,  unless  it  is 
limited  to  a  small  part  of  the  gland.  General  heat  of  the  breast, 
tenderness  and  induration  extending  over  a  considerable  part  of  it, 
are  signs  which  indicate  the  immediate  removal  of  the  infant  from 
it.  Lactation  must  be  restricted  to  the  unaflected  side.  It  is 
often  the  case  that  the  volume  of  the  inflamed  gland  is  considerably 
increased  from  the  afflux  of  blood  to  it,  and  from  the  interstitial 
exudation,  while  it  contains  little  or  no  milk,  and  attempts  at  lac- 
tation, under  such  circumstances,  are  injurious  to  the  mother  as 
well  as  infant.  The  cause  of  the  swelling  should  be  explained  to 
the  mother,  who  commonly  attributes  it  to  the  accumulation  of 
milk,  and  worries  herself  and  the  infant,  in  attempting  to  make  it 
nurse.  As  the  inflammation  abates,  by  resolution,  or  more  com- 
monly by  suppuration,  and  the  normal  secretion  returns,  the  first 
milk,  which  is  apt  to  be  thick  and  stringy,  should  be  rejected,  after 
which  the  infant  may  nurse  as  usual.  Occasionally,  the  abscess, 
which  has  formed  in  the  breast,  connects  with  a  lactiferous  tube, 
so  that  pus  may,  on  suction,  escape  from  the  nipple.  If  this  occur, 
of  course,  lactation  should  be  interdicted,  until  pure  milk  is  ob- 
tained. Pus  in  the  milk  can  sometimes  be  detected  by  the  naked 
eye.  It  presents  a  yellowish  or  greenish  color,  occurring  in  streaks, 
when  not  intimately  mixed  with  the  milk.  When  it  is  intimately 
mixed,  and  in  small  quantity,  it  cannot  be  detected  by  the  naked 
eye,  but  the  microscope  reveals  the  pus  globules.  M.  Donne  relates 
a  case  in  which  he  discovered  pus  globules  by  the  microscope, 
although  there  were  at  first  no  other  evidences  of  an  abscess,  and 
doubts  were  expressed  in  reference  to  the  accuracy  of  his  observa- 
tion.    Finally,  an  abscess  pointed  and  discharged. 

Sometimes,  when  the  inflammation  abates,  the  secretion  does 
not  return,  and,  worse  still,  occasionally  the  inflammation  has 
occurred  so  near  the  nipple  that  the  lactiferous  tubes  are  perma- 
nently closed  by  it,  so  that,  though  milk  forms  in  the  breast,  there 
is  no  escape  for  it.  Thenceforth  lactation  must  be  entirely  from 
one  breast. 

Facts  and  Rules  in  reference  to  Lactation, 

The  new-born  infant  should  nurse  every  hour,  or  every  second 
hour,  during  the  day.     At  night,  if  the  mother  is  delicate,  and  her 
3 


34 


LACTATION. 


milk  not  abundant,  it  may  be  fed,  once  or  twice,  with  a  little  cow's 
milk.  It  is  better  to  select,  for  this  purpose,  the  upper  third  of 
the  milk,  after  it  has  stood  two  or  three  hours,  and  use  it  diluted 
with  twice  the  quantity  of  water.  If  the  mother  is  robust,  she 
should  not  feed  the  infant,  but  allow  it  to  nurse  once  or  twice  dur- 
ing the  night.  No  nursling,  in  ordinary  health,  really  requires  the 
breast  more  than  once  during  the  hours  which  the  mother  needs 
for  rest ;  and  by  a  little  perseverance  on  her  part  its  habits  may  be 
so  established  that  it  is  satisfied  if  it  receives  the  breast  no  oftener. 
Many  young  mothers  commence  the  duty  of  suckling  with  too 
much  ardor.  Exerting  themselves  to  the  utmost  for  the  good  of 
their  offspring,  they  are  awake,  night  after  night,  giving  their 
breast  at  every  cry,  till  they  find  that  their  strength  is  failing,  and 
with  it,  also,  their  milk.  Their  self-devotion  necessitates  early 
weaning,  whereas,  had  they  exercised  more  regard  for  their  own 
health,  and  learned  to  hear  with  composure  the  cries,  which  often 
do  not  indicate  any  bodily  want  or  distress,  they  might  continue 
to  suckle  their  infants  during  the  usual  period. 

The  milk  secreted  during  gestation,  and  immediately  after  the 
birth  of  the  infant,  differs  in  its  gross  appearance,  as  well  as  che- 
mical and  microscopical  characters,  from  that  which  is  ordinarily 
secreted  in  a  state  of  health.  It  is  termed  colostrum.  It  has  a 
turbid  and  yellowish  appearance,  and  is  somewhat  viscid.  It  is 
decidedly  alkaline,  and  undergoes  lactic  acid  fermentation  more 
readily  than  common  milk,  and  it  also  contains  more  solid  matter. 
It  has  an  excess  of  fat,  of  salts,  and,  according  to  Simon,  also  of 
sugar.  It  appears,  from  Simon's  analysis,  that  the  solid  matter  of 
colostrum  is  about  seventeen  per  cent.,  while  that  of  the  ordinary 
breast-milk  is  about  eleven  per  cent. 


cfo'^;?< 


_      Oo   oo 


y^Q>, 


Milk  Globules. 


Colostrum  Corpuscles. 


Examined  by  the  microscope,  the  colostrum  is  seen  to  contain 
oil  globules  and  a  viscid  substance,  which  often  assumes  an  ovoid 
or  globular  form,  but  which  also  exists  in  irregular  masses  of  con- 


FACTS  AND  RULES  IN  REFERENCE  TO  LACTATION.   35 

siderable  size.  This  substance  has  been  thouglit  by  some  to  be 
mucus,  but  it  is  dissolved  by  acetic  acid  and  potash,  and  is  tinged 
yellow  by  a  watery  solution  of  iodine.  It  is,  therefore,  to  be 
regarded  as  albuminous.  Imbedded  in  this  substance  are  oil  glo- 
bules, which  are  for  the  most  part  of  small  size,  while  the  free  oil 
globules  of  colostrum  are  larger  than  those  occurring  in  healthy 
milk.  This  viscid  substance,  with  the  imprisoned  oil  globules, 
constitutes  what  has  been  designated  the  "colostrum  corpuscles." 
Some  have  erroneously  considered  the  "colostrum  corpuscles"  to 
be  compound  granular  cells.  The  compound  granular  cell,  or  cor- 
puscle, is  a  cell  which  has  undergone  fatty  degeneration.  It  is 
distended  with  oil  globules  to  perhaps  twice  or  thrice  its  normal 
size.  On  the  other  hand,  examination  of  the  "colostrum  corpus- 
cles" fails  to  detect  a  cell-wall,  and  the  large  and  irregular  size  of 
some  of  these  corpuscles  negatives  the  idea  that  they  are  cells. 
The  oil  globules  contained  in  the  viscid  substance  are  more  readily 
acted  on  by  ether  than  are  the  free  oil  globules. 

The  colostrum  is  replaced  by  milk  of  the  normal  character,  in 
six  to  eight  days ;  sometimes  as  early  as  the  third  or  fourth  day 
after  delivery.  In  exceptional  instances,  the  colostrum  does  not 
disappear  for  several  weeks,  and  it  may  reappear  at  any  time  dur- 
ing lactation,  as  a  consequence  of  derangement  of  the  system,  or 
from  disease.  It  is  assimilated  with  difficulty  by  the  digestive 
organs  of  the  infant,  producing  usually  a  laxative  effect.  It,  there- 
fore, aids  in  the  removal  of  the  meconium,  and  being  a  normal 
secretion  in  the  first  week  of  lactation,  it  is  to  be  regarded  as  bene- 
ficial. Continuing  longer  than  the  first  week,  its  effect  is  delete- 
rious. It  produces  evident  derangement  of  the  digestive  organs, 
and  the  infant  that  habitually  nurses  it,  never  thrives.  It  has 
diarrhoea  or  vomiting,  becomes  more  or  less  emaciated,  and  suffers 
from  colicky  pains.  Sometimes  an  extreme  degree  of  exhaustion 
is  reached  before  the  cause  is  suspected,  for,  if  the  milk  is  pretty 
abundant,  the  admixture  of  colostrum  with  it  cannot  be  detected 
by  the  naked  eye.  The  microscope  alone  reveals  it.  The  following 
is  an  interesting  example  of  this  fact.  In  1868  an  infant  six  weeks 
old  was  brought  to  me,  with  the  following  history.  The  mother 
had  for  years  been  troubled  more  or  less  with  dyspeptic  symptoms, 
but  had  otherwise  been  in  good  health.  The  infant  at  birth  was 
fleshy  and  strong,  but  after  the  first  week  it  had  never  thriven  like 
other  infants.  It  nursed  regularly,  and  the  quantity  of  milk  was 
apparently  sufficient,  but  it  vomited  as  soon  as  it  ceased  nursing ; 
it  was  much  emaciated,  and  the  bowels  were  habitually  constipated. 


86  LACTATION, 

The  digestive  organs  of  the  infant  had  been  in  this  unhealthy  state, 
with  little  variation,  from  the  first  week,  and  it  was  very  evident, 
from  the  emaciation  and  exhaustion,  that  it  must  soon  perish, 
unless  some  change  were  efiected.  The  milk  of  the  mother  presented 
the  usual  appearance  to  the  naked  eye,  but  under  the  microscope 
colostrum  corpuscles  were  observed.  A  wet-nurse  was  immediately 
obtained,  and  from  that  moment  the  gastro-intestinal  symptoms 
disappeared,  with  a  rapid  recovery.  This  case  shows  at  once  the 
evil  effects  of  the  colostrum,  and  the  need  of  a  microscopic  exami- 
nation of  the  milk  whenever  the  nursling  suffers  from  lactation. 

Human  Milk. 

The  specific  gravity  of  human  milk  is  about  1032.     It  has  been 

carefully  analyzed  by  difterent  chemists,  with  nearly  the   same 

result.     The  following  table,  prepared  by  MM.  Vernois  and  Bec- 

querel,  gives  the  proportion  of  the  various  ingredients  in  1000 

parts : — 

Water 889.08 

Sugar 43.64 

Caseum  and  Extractive 39.24 

Butter 26.66 

Salts  (ash) 1.38 

1000.00 

Milk  being  the  sole  food  of  early  infancy,  contains  all  the  nutri- 
tive principles  which  are  required  for  the  growth  and  repair  of  the 
different  tissues.  The  caseum  is  an  albuminous  principle,  the  butter 
and  sugar  are  combustible  substances,  and  most  of  the  salts  which 
occur  in  the  difterent  tissues  exist  primarily  in  the  milk.  Phos- 
phate of  lime,  phosphate  of  magnesia,  phosphate  of  the  peroxide  of 
iron,  chloride  of  potassium,  chloride  of  sodium,  and  soda,  known 
to  exist  in  cow's  milk,  are  believed  to  occur  also  in  human  milk. 
Epithelial  cells  are  sometimes  present,  derived  from  the  lining 
membrane  of  the  lactiferous  tubes. 

Modifications  of  the  Milk  in  Consequence  of  the  Diet. 

Fresh  milk  should  give  an  alkaline  reaction,  but  in  certain  states 
of  ill  health,  or  after  the  use  of  certain  articles  of  food,  the  reaction 
is  acid.  Mothers  are  well  aware  of  the  ill  effects,  as  regards  the 
infant,  which  follow  their  use  of  indigestible,  or  acescent  food ; 
and,  if  prudent,  they  avoid  it.  The  milk,  if  the  diet  of  the  mother 
is  improper,  may  become  so  strongly  acid  as  to  cause  colicky  pains 


MODIFICATIONS    OF    MILK    IN    CONSEQUENCE    OF    DIET.      37 

and  diarrhooa.  The  following  observations  in  reference  to  cow's 
milk  are  instructive.  "We  may  infer  from  them  that  the  regimen 
of  the  mother  exerts  a  decided  influence  on  the  alkalinity  of  her 
milk.  According  to  Routh  [Infant  Feeding,  page  285),  stall-fed 
cows  almost  always  give  acid  milk.  Dr.  Mayer,  of  Berlin,  exam- 
ined the  milk  from  a  considerable  number  of  cows,  with  the  follow- 
ing result : — 

{a.)  Of  cows  fed  with  brewers'  lees,  red  potatoes,  rye  bran,  and 
wild  hay,  in  five  instances  the  milk  was  slightly  sour;  in  one  very 
much  so. 

{b.)  Of  forty  cows  fed  with  potato  mash,  barley  husk,  and  clover 
and  barley  straw,  in  ten,  which  were  examined, the  milk  was  sour; 
in  three  very  sour. 

{c.)  From  among  fifty  cows  fed  on  j)otato  husks,  barley  husks, 
and  wild  hay,  five  were  examined,  and  in  all  the  fresh  milk  was 
sour. 

{(I.)  From  forty-two  cows  fed  on  potato  mash,  husks,  w^ild  hay, 
and  rye  straw,  out  of  twelve  selected  for  examination,  the  fresh 
milk  of  all  was  sour. 

{e.)  From  six  cows  fed  by  a  chief  gardener  on  coarse  beet-root, 
red  potato,  bran  mash,  and  hay,  the  fresh  milk  was  slightly  sour. 

(/.)  From  five  cows  fed  by  a  cow-feeder  on  lukewarm  bran  mash 
and  hay,  in  four  the  fresh  milk  was  quite  neutral,  in  one  it  was 
decidedly  alkaline.     [Routh.) 

The  above  observations  of  Dr.  Mayer  were  made  in  the  winter 
season,  and  it  is  possible  that  the  acidit}^  may  have  been  partly  due 
to  the  confinement  of  the  cows  in  stalls.  But  that  it  was  mainly 
due  to  the  food  is  evident  from  the  fact  that  it  was  greater  with 
some  kinds  of  food  than  others.  Cows'  milk  is  not  so  alkaline  as 
human  milk,  and  is  therefore  more  readily  rendered  acid.  Still, 
what  Dr.  Mayer  observed  in  reference  to  the  cow  exemplified  a  fact 
of  general  applicability,  namely,  that  certain  kinds  of  food  may 
affect  the  alkalinity  of  the  milk,  whether  human  milk  or  that  of 
animals. 

The  relative  proportion  of  the  different  ingredients  of  the  milk 
varies  according  to  the  diet.  If  the  diet  is  poor,  the  amount  of 
water  increases,  and  that  of  butter  and  caseum  diminishes.  Leh- 
mann  says  [Phys.  Chemistry,  vol.  ii.  p.  65):  "From  experiments 
made  on  bitches,  it  would  appear  that  a  vegetable  diet  renders  the 
milk  richer  in  butter  and  sugar ;  while  the  solid  constituents  are 
augmented  when  a  sufficient  quantity  of  mixed  food  is  given. 
Peligot  found  the  milk  of  an  ass  most  rich  in  casein  when  the 


88  LACtATION. 

animal  had  been  fed  on  beet-root ;  whilst  it  was  richest  in  butter 
when  the  food  had  consisted  of  oats  and  lucerne.  Fat  food  in- 
creases the  quantity  of  the  butter.  Boussingault  found  the  milk 
of  a  cow  richer  in  casein  when  the  animal  had  been  fed  on  potatoes 
than  when  other  food  was  taken.  Eeiset  found  that  the  milk  of 
cows  which  were  at  grass  was  much  richer  in  fat  than  when  the 
animals  had  stood  all  night  in  their  stall  without  food ;  but  Plaj- 
fair  found,  on  the  contrary,  that  the  quantity  of  butter  in  the  milk 
increased  during  the  nio-ht  as  much  as  during  their  stall-feedino;, 
but  that  the  quantity  of  butter  in  the  milk  was  considerably  dimin- 
ished by  the  motion  of  the  animals  in  the  fields."^  Simon  made 
the  following  analyses  of  the  milk  of  a  poor  woman.  She  was 
suddenly,  during  the  period  of  lactation,  deprived  of  the  means  of 
support,  so  that  her  food  was  insufficient  in  quantity,  and  of  poor 
quality.  The  amount  of  her  milk  was  not  diminished  by  priva- 
tion, but  the  solid  constituents  were  reduced  to  86  parts  in  1000. 
After  this,  for  a  time,  her  diet  was  nutritious  and  abundant,  the 
quantity  of  milk  was  increased,  and  the  solid  constituents  amounted 
to  119  parts  in  1000.  Her  diet  was  again  reduced,  with  a  reduction 
of  the  solid  elements  to  98  in  1000,  and,  at  a  later  period,  the  diet 
was  again  nutritious,  with  an  increase  of  the  solid  elements  to  126. 
The  chief  variation  observed  in  the  milk  of  this  woman  was  in  the 
amount  of  butter. 

Modification  of  Milk  from  its  Retention  in  the  Breast. 

M.  Peligot  has  clearly  demonstrated,  that  the  longer  milk  is 
retained  in  the  breast  the  more  watery  it  becomes.  This  is  ex- 
plained on  the  supposition  that  the  solid  portion  is  first  absorbed. 
Therefore,  the  milk  is  richer  the  more  frequently  it  is  removed 
from  the  breast.  A  similar  fact,  which  has  the  same  explanation, 
has  long  been  known,  namely,  that  the  first  milk  taken  from  the 
breast  is  thinnest,  while  that  which  flows  last  is  richest.  That 
first  removed  has  remained  longest  in  the  gland,  while  that  which 
comes  last  is  but  recently  secreted. 

A  knowledge  of  this  fact  is  of  considerable  practical  importance. 
The  milk,  as  M.  Donnd  has  shown,  may  be  too  rich,  so  as  to  cause 
indigestion,  with  more  or  less  enteralgia,  in  the  infant.  Some 
nurslings,  if  the  milk  is  too  rich  and  abundant,  reject  a  part  of  it 
by  vomiting,  but  others  do  not,  and  suft'er  the  consequence  in  de- 

'  Animal  Chem.,  Sydenham  Soc.'s  Trans.,  vol.  ii.  p.  55. 


MODIFICATION    OF    MILK    BY    NERVOUS    IMPRESSIONS.      39 

rangoment  of  the  digestive  organs.  For  such  cases  the  remedy  is, 
to  give  the  breast  less  frequently,  by  which  a  less  amount  of  milk 
is  taken,  and  milk  of  a  poorer  quality.  On  the  other  hand,  if  there 
is  poverty  of  the  milk,  and  the  infant  is  insufficiently  nourished,  the 
milk  is  more  nutritious  if  the  nursing  be  at  short  intervals. 

Modification  of  Milk  by  Age  and  by  Nervous  Impressions. 

The  composition  of  the  milk  varies,  also,  according  to  the  age 
of  the  infant.  Simon  analyzed  the  milk  of  a  woman  at  intervals 
for  the  period  of  about  six  months.  In  this  case  the  amount  of 
casein  at  first  was  small,  but  the  quantity  increased  during  the  two 
months  succeeding  delivery,  after  which  it  was  nearly  stationary. 
A  similar  increase  was  observed  in  reference  to  the  saline  sub- 
stances. The  sugar,  on  the  other  hand,  diminished  in  quantity  as 
the  infant  grew  older,  its  maximum  amount  being  in  the  first  and 
second  months.  The  quantity  of  butter  in  the  milk  varies  from 
day  to  day  more  than  the  other  elements. 

Many  observations  have  been  published  which  show  that  the 
composition  of  the  milk  may  be  materially  changed  by  mental 
impressions.  The  infant  has  died  suddenly  in  the  act  of  nursing, 
after  the  mother  had  been  violently  excited.  Such  a  case  is  related 
by  Tourtnal.  The  infant  ceased  nursing,  gasped,  and  died  in  the 
mother's  lap.  In  other  cases  convulsions  have  occurred.  MM. 
Becquerel  and  Vernois  made  the  chemical  analysis  of  the  milk  of 
a  woman  in  a  state  of  nervous  excitement,  and  found  that  the 
solid  constituents  were  diminished  to  91  parts  in  1000,  the  most 
marked  diminution  being  in  the  butter,  which  was  only  about  5 
parts.  In  a  case  related  by  Parmentier  and  Deyeux  the  milk 
became  watery  and  viscid,  and  remained  so  till  the  nervous  at- 
tacks, from  which  the  patient  sufiiered,  had  ceased.  Dairymen 
are  well  aware  how  ill-treatment  and  the  separation  of  the  calf 
from  the  cow  diminishes  the  milk  which  she  yields.  A  new  milk- 
man seldom  obtains  as  much  milk  as  one  with  whom  the  cow  is 
familiar.  Bouchut,  alluding  to  the  influence  of  the  moral  affec- 
tions on  the  secretion  of  milk,  makes  the  following  remark,  the 
truth  of  which  most  mothers  will  acknowledge :  "  It  is  also  a  fact, 
that  the  sight  of  the  nursling,  the  idea  of  seeing  it  at  the  breast, 
and  the  joy  which  certain  mothers  thence  experience,  exercise  a 
moral  influence  over  the  secretion  of  the  milk  entirel}^  independent 
of  their  will.  They  feel  the  draught  of  milk  as  soon  as  they  behold 
their  child,  or  think  of  it  too  deeply ;  and  in  a  woman  who  saw 


40  LACTATION. 

her  cliild  fall  to  the  ground,  the  flow  of  milk  ceased,  and  did  not 
reappear  until  the  child,  having  quite  recovered,  attempted  to 
take  the  breast." 

Modification  of  Milk  by  the  Catamenial  Function  and  Pregnancy. 

The  catamenia  reappear  in  most  women  before  the  close  of  lacta- 
tion, often  by  the  fifth  or  sixth  month  after  delivery.  If  this 
function  is  re-established  in  the  normal  manner,  that  is,  without 
any  derangement  of  the  system,  without  pain  or  undue  profuse- 
ness,  no  unfavorable  result  ordinarily  occurs  with  the  infant.  On 
the  other  hand,  if  the  mother  sufler  any  disturbance  of  the  system, 
or  if  the  menses  are  profuse,  the  lacteal  secretion  may  be  so  changed, 
that  the  infant  is  injuriously  affected  by  it.  The  symptoms  pro- 
duced are  those  of  indigestion,  such  as  abdominal  pains,  more  or 
less  vomiting,  and  diarrhoea.  This  result  is,  however,  in  my  ex- 
perience, quite  exceptional.  In  rare,  instances,  more  dangerous 
symptoms  occur  in  the  infant.  A  case  has  been  reported  to  me  in 
which,  at  each  catamenial  period,  the  nursling  was  seized  with 
convulsions. 

MM.  Becquerel  and  Vernois  have  investigated  the  character  of 
the  milk  durins:  the  catamenia  in  three  cases.  Their  examinations 
showed  a  moderate  increase  in  the  solid  constituents.  The  butter 
and  caseum  were  increased,  while  the  sugar  was  diminished.  The 
variation  from  normal  milk  was  not,  however,  such  as  would  be 
likely  to  cause  any  serious  indisposition.  If  the  menses  reappear 
•vvith  regularity,  when  the  infant  has  attained  the  age  of  ten  or 
twelve  months,  they  should  be  considered  as  designed  to  supersede 
the  secretion  of  milk,  which,  indeed,  usually  begins  to  diminish. 
Weaning  is  then  proper.  If  the  menses  return  early  in  the  period 
of  lactation,  and  give  rise  to  symptoms  in  the  infant  in  consequence 
of  the  altered  quality  of  the  milk,  it  is  advisable  to  allow  but  little 
nursing  during  the  catamenia,  and  to  employ  artificial  feeding  in 
place  till  the  flow  of  blood  ceases. 

The  change  produced  in  the  milk  by  pregnancy  is,  in  general, 
more  injurious  to  the  nursling  than  that  caused  by  the  reappear- 
ance of  the  menses.  The  milk  of  the  pregnant  woman  is  apt  to 
contain  more  or  less  of  that  viscid  substance  which  characterizes 
colostrum.  Still,  the  milk  of  pregnancy  does  not,  ordinarily,  de- 
rano-e  the  dio;estive  function  as  much  as  colostrum,  in  the  first 
weeks  of  lactation,  for  pregnancy  rarely  occurs  till  after  the  infant 
is  five  or  six  months  old,  when  the  organs  of  digestion  are  less 


QUANTITY    OF    BKEAST    MILK    REQUIKED    BY    INFANT.      41 

readily  disturbed.  The  injurious  effect  of  pregnancy  on  the  infant 
is  sliown  by  vomiting  or  diarrhoea,  l)y  restlessness  and  occasional 
abdominal  pains,  in  fine,  by  symptoms  of  indigestion.  In  many 
cases,  however,  these  symptoms  do  not  occur,  and  the  infant,  though 
nursing  regularly,  continues  to  thrive.  ISTo  doubt,  as  a  rule,  the 
infant  should  be  weaned  when  there  are  clear  evidences  of  preg- 
nancy, but  under  certain  circumstances  weaning  is  injudicious.  I 
have,  on  different  occasions,  been  called  to  infants,  in  midsummer, 
dangerously  sick  with  diarrhoeal  attacks  induced  by  this  cause. 
These  infants  were,  perhaps,  doing  well,  or  sufiering  but  little  from 
indigestion,  when  the  mothers  suspecting  themselves  pregnant,  at 
once  withdrew  them  from  the  breast,  and  cholera  infantum  or  a 
kindred  disease  was  the  result.  ISTo  infant  in  the  city  should  be 
weaned  in  the  hot  months.  It  is  much  safer,  though  there  are 
indubitable  signs  of  pregnancy,  that  it  continue  nursing  till  the 
cold  weather.  The  better  method  is,  however,  under  such  circum- 
stances, to  employ  a  wet-nurse,  or  to  remove  the  infant  to  the 
country,  and  wean  it  there.  In  cold  weather,  it  is  usually  safe  to 
wean  an  infant,  in  the  city,  after  it  has  reached  the  age  of  five  or 
six  months. 

The  milk  frequently  contains  other  ingredients  in  addition  to 
those  which  have  been  mentioned.  Thus  a  large  number  of  medi- 
cinal substances,  taken  by  the  mother,  may  enter  the  milk,  so  as  to 
produce  their  characteristic  effect  on  the  infant.  It  is  a  well-known 
fact,  that  the  peculiar  flavor  of  certain  vegetables,  taken  as  food, 
may  be  noticed  in  the  milk.  It  is  admitted,  also,  that  the  specific 
virus  of  the  contagious  diseases,  at  least  certain  of  them,  may  enter 
the  milk,  so  as  to  give  rise  to  the  same  diseases  in  the  infant. 


Quantity  of  Breast  Milk  required  by  the  Infant. 

In  a  paper  published  by  Dr.  W.  H.  Gumming,  in  the  American 
Journal  of  Medical  Science,  July,  1858,  it  is  estimated  that  the 
amount  of  milk  secreted  per  day  by  a  healthy  women  is  one  and 
a  half  to  two  quarts,  and  double  the  quantity  if  two  infants  are 
suckled.  Routh  {Infant  Feeding,  P^^ge  87)  believes  that  this  is  a 
somewhat  exasrserated  statement.  He  estimates  the  amount  at  a 
quart  to  a  quart  and  a  half  daily.  "A  three  months  child,'"  says 
he,  "  generally  thrives  very  well  on  four,  or,  at  the  most,  five  meals 
a  day,  the  quantity  taken  each  time  amounting  to  a  half-pint.  This 
would  fix  the  quantity  at  two  pounds  to  two  and  a  half,  i.e.,  thirty- 
two  to  forty  fluidounces.   ...  A  younger  child,  one  to  two  months, 


42  LACTATION. 

may  need  to  take  his  meals  more  frequently — it  may  be  every  two 
hours,  except  when  asleep — but  then  the  quantity  consumed  does 
not  exceed,  as  a  rule,  as  I  have  often  assured  myself,  two  wine- 
glasses or  three  ounces  every  meal.  This  would  raise  the  quantity 
taken  in  twenty-four  hours  to  thirty-six  ounces — a  quart  and  a 
quarter.  A  child  above  three  months  may  take  about  forty-eight 
ounces  dail3^" 

Dr.  Gumming,  in  consequence  of  his  high  estimate  of  the  amount 
of  milk  which  an  infant  requires,  naturally  concludes  that  few 
mothers  can  long  endure  the  excessive  drain  upon  their  systems, 
and  therefore,  in  order  to  prevent  their  exhaustion,  and  to  satisfy 
the  appetite  of  their  infants,  it  is  necessary,  at  an  early  period,  to 
aid  by  artificial  feeding.  This  opinion  may  do  harm,  since  artificial 
feeding  of  the  young  infant,  especially  in  the  cities,  is  apt  to  give 
rise  to  indigestion,  followed  by  vomiting  and  diarrhoea.  The  mother 
in  good  health,  and  furnishing  an  average  quantity  of  milk,  is 
competent  to  give  all  the  nutriment  which  the  infant  requires 
until  it  has  reached  the  age  of  four  months,  and  most  are  till  the 
age  of  six  months.  Drs.  Merei  and  Whitehead  examined  952 
mothers  in  the  Children's  Hospital  at  Manchester,  in  reference  to 
their  physical  condition.  Of  these,  629,  or  Q6  per  cent.,  were  in  a 
healthy  and  robust  state.  Of  this  number,  namely  629,  420  fur- 
nished suflicient  milk  till  six  months  after  delivery,  and  some  till 
two  years. 

Differences  in  Suckling  Women  as  regards  Quantity  and  Quality  of  Milk. 

There  is,  however,  a  great  difference,  in  different  women,  as 
regards  the  quantit}^  and  quality  of  their  milk,  and  even  the  mode 
in  which  it  is  secreted.  The  best  wet-nurses  are  usually  robust 
without  being  corpulent.  Their  appetite  is  good,  and  their  breasts 
are  distended  from  the  number  and  large  size  of  the  bloodvessels 
and  milk-ducts.  There  is  but  a  moderate  amount  of  fat  around 
the  gland,  and  tortuous  veins  are  observed  passing  over  it.  Such 
nurses  do  not  experience  a  feeling  of  exhaustion  and  do  not  suffer 
from  lactation. 

The  nutriment  which  they  consume  is  equally  expended  in  their 
own  sustenance  and  the  supply  of  milk.  There  are  other  good 
wet-nurses  who  have  the  physical  condition  which  I  have  described, 
but  whose  breasts  are  small.  Still,  the  infant  continues  to  nurse 
till  it  is  satisfied,  and  it  thrives.  The  milk  is  of  good  quality,  and 
it  appears  to  be  secreted,  mainly,  during  the  time  of  suckling. 


SCANTINESS    OF    MILK.  43 

Otlier  mothers  evidently  decline  in  health  during  the  time  of  lac- 
tation. They  furnish  milk  of  good  quality  and  in  abundance,  and 
their  infants  thrive,  but  it  is  at  their  own  expense.  They  them- 
selves say,  and  with  truth,  that  what  they  eat  goes  to  milk.  They 
become  thinner  and  paler,  are  perhaps  troubled  with  palpitation, 
and  are  easily  exhausted.  They  often  find  it  necessary  to  wean 
before  the  end  of  the  usual  period  of  lactation.  There  is  another 
class  whose  health  is  habitually  poor,  but  who  furnish  the  usual 
quantity  of  milk  without  the  exhaustion  experienced  by  the  class 
which  I  have  just  described.  The  milk  of  these  women  is  of  poor 
quality.  It  is  abundant,  but  watery.  Their  infants  are  pallid, 
having  soft  and  flabby  fibre.  All  these  kinds  of  wet-nurses  are 
met  in  practice. 

Occasionally,  a  considerable  part  of  the  milk  is  lost  by  oozing 
from  the  breast.  This  sometimes  occurs  in  robust  women,  but  it 
is  more  frequently  associated  with  weakness.  It  is  then  due  to  a 
relaxed  state  of  the  orifices  of  the  milk-ducts.  Galactorrhoea,  as 
the  excessive  secretion  and  flow  of  milk  is  designated,  is  said  to 
be  often  associated  with  a  menorrhagic  diathesis ;  that  is,  women 
whose  menses  have  been  profuse  are  apt  to  have  too  abundant  a 
flow  of  milk  corresponding  with  the  menorrhagia.  It  is  said  that 
galactorrhoea  is  also  apt  to  occur  in  those  who  are  subject  to  dis- 
charges from  parts  which  sustain  no  immediate  relation  to  the 
breast,  as  in  cases  of  hsemorrhoidal  flux,  diabetes  insipidus,  etc. 
Excitement,  or  irritation  of  the  uterus  or  ovaries,  may  serve  as 
an  exciting  cause  of  galactorrhcea  in  those  predisposed  to  it,  and 
excessive  suckling  may  have  the  same  eflect. 

Scantiness  of  Milk;   its  Causes  and  Treatment. 

Though  the  amount  of  breast-milk  which  the  infant  requires  is 
less  than  was  estimated  by  Gumming,  still  insuflSciency  of  this 
secretion  is  not  uncommon,  especially  in  the  cities.  According  to 
the  statistics  of  Drs.  Merei  and  Whitehead,  among  healthy  mothers 
there  is  insufiiciency  in  16.5  per  cent.,  while  among  mothers  in 
feeble  health  the  percentage  is  46.6.  In  treating  of  this  subject 
in  the  following  pages,  reference  is  not  had  to  those  cases  in  which 
there  is  temporary  diminution  of  milk  from  acute  disease  or  other 
perturbating  causes,  but  to  those  cases  in  which  there  is  habitual 
scantiness. 

One  cause  of  scanty  secretion  of  milk  is  a  life  of  privation  or  of 
daily  w^ork,  which  necessitates  separation  from  the  infant.     Insuf- 


44  LACTATION. 

ficient  food  may  render  the  milk  more  watery,  as  has  ah-eady  been 
stated,  or  it  may  cause  diminution  in  its  quantity.  The  mother 
thus  situated  is  pallid.  She  is  subject  to  palpitation  and  attacks 
of  faintness.  Her  condition,  indeed,  is  that  of  anaemia.  Working 
women  have  scantiness  of  milk,  not  only  in  consequence  of  hard- 
ships, but  also  because  they  are  usiially  separated  for  hours  from 
their  infants.  Age  is  also  a  cause  of  scantiness  of  milk.  Mothers 
at  the  age  of  forty  years  ordinarily  furnish  less  milk  than  between 
twenty  and  thirty.  And  those  who  have  not  borne  children  till 
late  in  life,  and  whose  mammary  glands  have  therefore  long  been 
inactive,  have  less  milk  than  those  who  commence  bearing  children 
at  the  usual  period. 

Routh  speaks  of  hyperemia  as  a  cause  of  defective  lactation. 
"  This  is  a  variety,"  says  he,  "  which  I  have  chiefly  observed  among 
hired  wet-nurses,  selected  from  the  poorer  classes,  and  admitted 
into  wealthier  families.  .  .  .  When  feeding  at  the  expense  of  a 
master  or  mistress,  the  amount  they  devour  often  surpasses  all 
moderate  imagination.  They,  in  fact,  gormandize.  If  in  such 
instances  a  wet-nurse  is  given  all  she  asks  for,  she  will  be  found 
often  to  eat  quite  as  much  as  any  two  men  with  large  appetites ; 
and,  as  a  result,  she  becomes  gross,  turgid,  often  covered  with 
blotches  or  pimples,  and  generally  too  plethoric  to  fulfil  the  duties 
of  her  position.  The  plethora,  as  first  induced,  is  of  the  sthenic 
variety,  but  it  soon  assumes  an  asthenic  character,  and,  as  the  im- 
mediate result,  the  breast  no  longer  secretes  its  quantum  of  milk. 
There  may  be  good  milk  secreted,  but  it  is  in  small  quantity,  and 
this  quantity  diminishes  daily.  The  breast  may  also  enlarge,  but 
it  is  from  a  deposition  of  fatty  tissue  in  and  about  it,  as  in  other 
parts  of  the  body.  The  veins  on  the  surface  become  less  apparent, 
always  a  bad  feature  in  a  suckling  breast,  till  finally  the  flow  of 
milk  ceases  altogether." 

Atrophy  of  the  breast  from  the  employment  of  iodine,  or  from 
long  disuse,  is  also  a  cause  of  insufficiency  of  milk. 

It  is  so  necessary  for  the  health  and  development  of  the  infant 
that  the  milk  should  be  in  proper  quantity  as  well  as  quality,  tliat 
it  is  proper  in  a  work  of  this  kind  to  consider  the  treatment  of 
insufiicient  secretion,  and,  on  the  other  hand,  of  excessive  secretion 
and  loss  of  milk,  or  galactorrhoea.  And  first  of  insufiicient  or 
scanty  secretion. 

The  most  efficient  mode  of  increasing  the  lacteal  secretion  is 
that  which  is  also  natural,  namely,  suction  from  the  nipple.  There 
are  many  cases  on  record  in  which  this  has  produced  the  flow  of 


SCANTINESS    OF    MILK.  45 

milk  in  women  who  have  never  borne  children,  and  even  in  men. 
Baudelocque  mentions  the  case  of  a  girl,  eight  years  old,  who 
snckled  her  brother  for  a  month,  and  cases  at  the  opposite  extreme 
of  life  have  been  reported;  one  of  a  woman  of  seventy  years,  who 
wet-nursed  a  grandchild  twentj^  years  after  her  last  confinement. 

Travellers  among  barbarous  nations  or  tribes  have  often  observed 
these  cases  of  unnatural  lactation.  Humboldt  saw  a  man,  thirty- 
two  years  old,  who  gave  the  breast  to  his  child  for  five  months,  and 
Captain  Franklin,  in  the  Arctic  regions,  met  a  similar  case.  Dr. 
Livingstone,  in  his  account  of  Africa,  says  that  he  has  examined 
several  cases  in  which  a  grandchild  has  been  suckled  by  a  grand- 
mother, and  equally  remarkable  instances  of  lactation  occur  among 
the  negroes  of  the  Southern  and  Middle  States.  Prof.  Hall  pre- 
sented to  his  class  in  Baltimore  a  male  negro  fifty-five  years  old 
who  wet-nursed  all  the  children  of  his  mistress.  In  these  cases 
of  abnormal  lactation,  so  far  as  we  have  complete  records  of  them, 
it  is  ascertained  that  the  breasts  were  torpid,  and  even  sometimes, 
as  in  old  people,  atrophied  till  the  nursing  commenced.  Titil- 
lation,  or  pressing  of  the  nipple,  caused  an  afilux  of  blood  to  the 
gland,  and  developed  its  functional  activity,  so  that  milk  was  pro- 
duced for  the  sustenance  of  the  nursling.  Therefore,  in  case  of 
scanty  secretion  of  milk,  the  mother  may  increase  the  quantity  by 
applying  the  infant  often  to  the  breast.  If,  dissatisfied  with  the 
small  amount  of  nutriment  which  it  receives,  it  refuses  to  make 
the  necessary  suction,  any  other  mode  of  gentle  traction  or  pres- 
sure may  be  employed  in  addition.  The  occasional  employment  of 
another  infant,  or  a  pup,  milking  the  breast  with  the  thumb  and 
fingers,  or  the  gentle  suction  of  a  breast  pump,  aids  in  stimulating 
the  secretion.  Forcible  rubbing  or  traction  of  the  breast  defeats 
the  purpose  for  which  it  is  employed.  It  produces  too  much  irrita- 
tion and  tenderness.  The  best  mode  of  stimulation  is  by  nursing, 
as  it  is  the  natural  mode,  and  the  moral  effect  of  the  infant  at  the 
breast  aids  in  promoting  the  secretion. 

Another  mode  of  increasing  the  functional  activity  of  the  mam- 
mary glands  is  by  the  electrical  current.  The  fact  is  established  by 
physiological  experiments,  that  glandular  organs  can  be  made  to 
secrete  more  actively  by  the  stimulus  of  electricity,  and,  accord- 
ingly, this  agent  has  been  successfully  employed  to  promote  the 
secretion  of  milk.  In  Routh's  Infant  Feeding  several  cases  are 
related  which  show  the  beneficial  effects  of  this  agent  (page  149 
et  seq.).  Among  them  are  six  reported  by  Dr.  Skinner,  of  Liver- 
pool.    In  all  these,  one  or  two  applications  of  the  electrical  current 


46  LACTATION. 

sufficed  ■  to  restore  the  secretion.     The  following  is  Dr.  Skinner's 
mode  of  employing  this  treatment : — 

"  1.  Direct. — Both  poles  must  terminate  in  cylinders,  with  sponges 
well  moistened  in  tepid  water.  The  positive  pole  is  pressed  deep 
into  the  axilla,  while  the  negative  is  lightly  applied  to  the  nipple 
and  the  areola  ;  the  current  being  no  stronger  than  is  agreeable  to 
the  patient's  feelings.  The  poles  are  kept  in  this  position  for  about 
two  minutes.  Both  poles  are  then  to  be  inserted  into  the  axilla, 
and  gradually  brought  together,  the  negative  to  the  sternal,  and 
the  positive  to  the  opposite  of  the  organ.  This  latter  step  may 
occupy  one  or  two  minutes  more. 

"  2.  Intraynammary. — The  poles  are  to  be,  as  it  were,  imbedded 
in  the  mamma,  and  moved  about,  raising  and  depressing  both  poles 
at  once  in  and  around  the  organ  for  the  space  of  another  two 
minutes.  The  same  is  to  be  done  to  both  breasts  daily,  until  the 
secretion  is  properly  established.  Hitherto  one  or  two  sittings 
have  always  sufficed  in  my  hands."  {Communication  of  Dr.  Skinner 
to  Dr.  Routh.) 

In  all  cases  of  scanty  secretion  of  milk,  the  regimen  of  the  mother 
is  a  matter  of  importance.  Personal  and  domiciliary  cleanliness 
is  essential  for  successful  wet-nursing.  A  certain  amount  of  ex- 
ercise in  the  open  air  is  conducive  to  the  health  of  the  mother,  and 
to  the  secretion  of  abundant  and  healthy  milk.  A  case  is  related 
to  show  the  effect  of  fresh  air  and  out-door  exercise  on  the  lacteal 
secretion.  A  lady  of  cleanly  habits,  living  in  London,  had  a  very 
scanty  supply  of  milk.  She  removed  to  the  pure  air  of  the  sea- 
shore, and  immediately  the  quantity  became  abundant,  and  con- 
tinued so  for  months.  Such  cases  are  not  unfrequent.  A  mode  of 
life  that  contributes  to  the  general  health  of  the  mother  will  not 
fail  to  augment  the  quantity  of  her  milk,  if  it  is  scanty,  and  to 
improve  its  quality. 

Much  has  been  written  in  reference  to  the  diet  of  women  who 
suckle.  It  is  a  popular  belief  that  certain  articles  of  food  promote 
the  secretion  of  milk  much  more  than  other  articles,  though  equally 
nutritious.  No  doubt,  writers  liave  erred  in  recommending  exclu- 
sively this  or  that  kind  of  food,  as  most  likely  to  produce  milk. 
The  exact  kind  of  food  which  is  preferable,  in  a  certain  case,  de- 
pends partly  on  the  physique  of  the  individual,  and  partly  on  the 
character  of  the  food  to  which  she  has  been  accustomed.  A  mixed 
diet  contributes  most  to  the  sustenance  of  the  mother,  and  to  an 
abundant  secretion  of  milk.  Animal  substances  which  furnish  a 
due  supply  of  nitrogenous  aliment  should  be  given  with  the  fari- 


SCANTINESS    OF    MILK.  47 

naceons.  Mothers  pallid,  and  inclining  to  an  anaemic  condition, 
require  a  larger  proportion  of  animal  diet  than  those  in  good 
general  health.  On  the  other  hand,  plethoric  women,  such  as 
Routh  describes,  who  with  excellent  appetites  consume  large  quan- 
tities of  food,  and  who  become  more  and  more  full-blooded  and 
corpulent  while  the  milk  diminishes,  require  a  more  -restricted 
animal  diet,  in  connection  with  more  exercise,  especially  in  the 
open  air. 

There  are  certain  kinds  of  food  which  do  ajDpear  to  have  a  galac- 
togogue  effect  with  most  wet-nurses.  Oatmeal  gruel  is  one  of 
these.  Wet-nurses  often  remark,  after  taking  a  bowl  of  this,  that 
they  feel  the  flow  of  milk.  Cow's  milk  with  some  has  a  similar 
effect.  Porter  or  ale,  taken  once  or  twice  a  day,  also  promotes  the 
secretion  of  milk,  especially  in  those  who  have  poor  appetite,  and 
whose  systems  are  somewhat  reduced. 

A  great  variety  of  medicines  have  been  used  for  their  supposed 
galactogogue  eflect.  Medicines  which  improve  the  general  health 
are,  no  doubt,  sometimes  useful  for  this  purpose,  such  as  the  vege- 
table and  ferruginous  tonics,  and  perhaps  cod-liver  oil.  But  there 
are  other  medicines  which  it  is  claimed  have  a  specific  eflect  on  the 
mammary  gland,  promoting  its  secretion.  Lettuce,  winter-green, 
fennel,  the  broom  tops  (cytisus  scoparius),  marsh-mallow,  castor  oil 
plant,  and  many  other  plants,  have  been  used  for  this  purpose. 
There  can  be  no  doubt  that  the  aromatic  stimulants,  as  fennel, 
anise,  and  caraway  seeds,  given  in  soups,  sometimes  stimulate  the 
lacteal  secretion.  But  the  medicine  which  of  late  has  attracted 
most  attention  in  the  profession,  as  a  galactogogue,  is  castor  oil  and 
the  plant  from  which  it  is  derived. 

The  galactogogue  effect  of  the  leaves  of  the  castor  oil  plant  has 
been  long  known  to  the  Spaniards  in  South  America.  At  least  as 
long  ago  as  the  commencement  of  the  last  century,  the  ricinus  com- 
munis was  applied  by  them  externally  to  the  breast,  to  promote  the 
secretion  of  milk.  It  is  now  about  twenty  years  since  this  use  of 
the  plant  was  brought  prominently  to  the  notice  of  the  profession 
in  this  country  and  in  Europe.  In  the  London  Journal  of  31edi- 
cine,  1857,  Dr.  Tyler  Smith  relates  the  results  of  his  experiments 
with  the  castor  oil  plant.  He  applied  the  bruised  leaves  over  the 
breasts,  and  witnessed,  as  he  thinks,  an  evident  galactogogue  effe'ct. 
Dr.  Routh  has  also  made  pretty  extensive  use  of  the  plant,  both 
externally  and  internally.  He  was  led,  he  says,  to  employ  it  in- 
ternally, from  noticing,  in  suckling  women,  an  increase  of  milk 
after  taking  a  dose  of  castor  oil.     He  prescribed  a  decoction  of  the 


48  LACTATION. 

leaves  and  stalks,  and  says :  "  I  have  not  been  disappointed.  The 
flow  has  been  remarkably  increased.  Four  objections  against  its 
use,  however,  should  be  mentioned."  These  are,  first,  a  peculiar 
sensation  in  the  eyes,  with  dimness  of  sight,  an  effect  which  he  has 
observed  only  in  weak  women ;  secondly,  the  necessity  of  increas- 
ing the  dose  as  the  patient  becomes  accustomed  to  it ;  thirdly, 
scarcity  of  the  plant ;  fourthly,  an  occasional  diuretic,  sometimes 
without  galactoo-oo-ue  effect,  and  sometimes  with  it.  The  cases  in 
which  diuresis  occurred  were  in  the  practice  of  other  physicians, 
and  Dr.  Routh  conjectures  that  this  effect  was  produced  by  not 
keeping  the  breast  warm  during  the  time  that  the  decoction  was 
being  employed.  The  breasts  should  at  the  time  of  its  use  be 
covered  with  a  fomentation  of  leaves,  or  an  extract  of  the  leaves 
should  be  rubbed  over  the  breasts  in  the  same  way  in  which  extract 
of  belladonna  is  used,  and  over  this  a  warm  poultice  applied  of 
the  ordinary  material.  Dr.  Routh  remarks:  "When  the  castor  oil 
leaves  are  given  as  an  infusion  to  women  who  are  not  suckling,  I 
have  observed  two  eft'ects,  both  of  which  seem  to  denote  its  specific 
action.  First,  it  produces  internal  pain  in  the  breasts,  which  lasts 
for  three  or  four  days.  Then,  secondly,  a  copious  leucorrhoeal  dis- 
charge takes  place,  after  which  the  effect  on  the  breasts  entirely 
disappears." 

Dr.  Gilfillan,  of  Brooklyn,  has  also  employed  the  ricinus  com- 
munis successfully  as  a  galactogogue.  He  employed  a  poultice  of 
the  pulverized  leaves,  and  gave  internally  the  fluid  extract  of  the 
leaves,  a  teaspoonful  three  times  daily.  The  patient  had  been  con- 
fined the  year  before  with  her  first  child,  but  had  no  milk  for  it, 
though  her  health  Avas  good,  and  measures  were  employed,  as  fric- 
tion and  fomentations,  to  stimulate  the  secretion.  The  ricinus  was 
prescri])ed  the  fourth  day  after  her  confinement  with  the  second 
child,  when  there  were  no  signs  of  secretion,  and  the  breasts  were 
small.  "About  two  hours  after  the  poultice  was  applied,  and  the 
first  dose  taken,  she  experienced  a  strange  sensation  in  the  breasts, 
and  this  increased  after  each  dose  of  the  medicine.  The  poultice 
was  not  renewedj  but  the  extract  was  continued  for  three  days, 
after  which  lactation  was  perfectly  successful."  So  far  observations 
have  shown  that  the  ricinus  is  the  most  efficient  galactogogue  which 
we  possess  among  medicinal  agents. 

In  the  treatment  of  galactorrhoea  the  object  to  be  attained  should 
be  kept  in  view.  There  are  medicines  which  cure  this  affection  by 
diminishing  the  amount  of  milk.  Belladonna,  iodide  of  potassium, 
and  colchicum  are  antigalactics.     It  is  proper  to  use  them  in  case 


SELECTION    OF    A    WET-NURSE.  49 

of  weaning  or  of  death  of  the  infant.  They  not  only  reduce  the 
quantity  of  milk,  but,  continued,  may  prevent  its  secretion.  They 
arc  employed  not  to  benefit  the  infant,  but  the  mother. 

On  the  other  hand,  if  it  is  our  purpose  to  prevent  the  oozing  of 
milk  in  order  to  save  it  for  the  infant,  or,  if  it  is  abundant  and 
watery,  to" diminish  somewhat  its  quantity  and  improve  its  quality, 
the  treatment  should  be  different.  Iron,  in  cases  of  galactorrhoea, 
in  which  the  condition  of  the  system  appears  to  indicate  the  need 
of  it,  Avill  diminish  the  quantity  of  milk  and  render  it  richer.  It 
is  by  many  regarded  as  an  antigalactic,  and  given  long  it  might 
reduce  too  much  the  amount  of  the  secretion,  and  even  necessitate 
weaning.  Its  use  should  be  discontinued  if  no  more  than  the 
normal  amount  of  milk  is  secreted. 

In  most  cases  of  true  galactorrhoea  the  pathological  state  is  that 
of  weakness  and  relaxation  of  the  tissues.  The  fault  is  not  exces- 
sive secretion  of  milk  so  much  as  its  non-retention,  and  the  medi- 
cines which  are  the  most  useful  to  correct  this  state  of  the  system 
and  of  the  breasts  are  the  vegetable  tonics  and  astringents.  If 
galactorrhoea  occur  in  those  who  have  an  habitual  discharge,  and 
it  appears  to  be  due  to  the  same  cause  which  produces  that  dis- 
charge, and  there  are  no  evidences  of  weakness,  laxative  medicines 
and  other  derivatives  may  be  employed.  But  such  cases  are  not 
common.  ISTux  vomica  has  been  recommended  in  galactorrhoea,  in 
the  belief  that  it  diminishes  the  relaxation  of  the  orifices  of  the 
lactiferous  tubes. 

Local  treatment  in  this  affection  is  important.  A  cloth  wrung 
out  of  cold  water  should  be  occasionally  applied  around  the  nipple, 
and  removed  as  it  becomes  warm.  Solutions  of  tannin  or  alum  are 
likewise  useful.  Collodion  applied  around  the  nipple,  by  its  retrac- 
tion, diminishes  the  orifices  of  the  ducts,  and  thus  aids  in  the  reten- 
tion of  the  milk. 


CHAPTER   Y. 

SELECTION  OF  A  WET-NURSE. 

In  the  cities,  cases  are  frequent  in  which  mothers,  with  all  pos- 
sible care  or  endeavor,  find  themselves  unable  to  suckle  their  infants. 
Their  health  is  too  poor,  or  the  milk  possesses  the  properties  of  colos- 
trum, or  it  is  no  longer  secreted  on  account  of  nervous  excitement, 
4 


50  SELECTION    OF    A    WET-NURSE. 

or  exhaustion,  or  inflammation  of  the  breasts.  The  number  of  such 
cases,  in  the  city,  would  surprise  physicians  who  are  familiar  only 
with  the  healthy  and  robust  mothers  of  the  country.  The  infant 
thus  deprived  of  the  mother's  milk  should,  if  practicable,  be  fur- 
nished a  wet-nurse. 

The  selection  of  a  wet-nurse  often  devolves  upon  the  physician, 
and  it  is  a  duty  of  great  responsibility.  It  is  better  to  select  one 
between  the  ages  of  twenty  and  thirty  years,  and  one  who  has 
suckled  an  infant  previousl}^  A  wet-nurse  between  the  ages  of 
twenty  and  thirty  is  usually  more  active,  cheerful,  and  conciliatory 
than  one  of  a  more  advanced  age,  and  her  milk  is  more  apt  to  be 
abundant  and  nutritious.  Those  who  have  previously  suckled  and 
had  charge  of  infants  are  obviously  more  competent  to  serve  as  wet- 
nurses  than  are  primiparse.  The  milk  of  a  wet-nurse,  whose  infant 
is  under  the  age  of  six  months,  will  ordinarily  agree  with  a  new- 
born infant.  If  above  that  age,  it  sometimes  agrees,  but  often  does 
not. 

The  most  diflScult  and  responsible  task  imposed  on  the  physician, 
in  the  selection  of  a  nurse,  is  to  ascertain  the  exact  condition  of  her 
health,  and  the  quantity  and  quality  of  her  milk.  Constitutional 
syphilis  is  common  in  the  class  of  women  who  present  themselves 
for  wet-nursing ;  it  is  often  latent,  or  its  symptoms  are  easily  con- 
cealed, and  it  is  communicable  by  lactation.  The  virus  may  be  re- 
ceived by  the  infant  from  fissures  or  excoriations  of  the  nipple.  The 
nursling  tainted  by  syphilis  may,  on  the  other  hand,  communicate 
the  disease  to  the  nurse  through  the  same  source.  It  is  not  fully 
ascertained  whether  the  syphilitic  virus  may  be  conveyed  to  the 
infant  by  the  milk.  But  the  cases  which  have  accumulated  in  the 
records  of  medicine  are  numerous,  in  which  infants  born  of  healthy 
parents  have  been  fully  syphilized  by  lactation  from  diseased  nurses 
(see  article  Syphilis).  These  infants  have  sometimes  led  a  short 
and  miserable  existence,  and  have  occasionally  increased  the  misery 
of  the  household  by  imparting  the  disease  to  others.  The  duty  is, 
therefore,  imperative  on  the  part  of  the  physician  to  examine  care- 
fully the  wet-nurse,  in  reference  to  any  evidences  of  the  syphilitic 
taint.  Acquainted  with  the  symptoms  of  syphilis,  he  may  usually, 
by  shrewd  questioning  and  by  careful  examination  of  the  present 
appearance  and  condition  of  the  woman,  ascertain  with  consider- 
able certainty  whether  her  system  has  ever  been  infected.  Refer- 
ences should  also  be  obtained  and  consulted,  and,  if  practicable,  the 
physician  who  has  attended  her  be  communicated  with. 


EXAMINATION    OF    THE    MILK.  51 

There  are,  also,  among  the  women  who  present  themselves  for 
wet-nursing  in  the  cities,  many  of  a  scrofulous  habit,  many  who 
possess  an  hereditary  tendency  to  tuberculosis,  if  indeed  they  do 
not  already  have  the  incipient  disease.  Such  applicants  should  be 
rejected,  on  account  of  the  poverty  of  their  milk  and  the  proba- 
bility that  they  will  not  be  able  to  endure  the  debilitating  effect  of 
lactation. 

The  milk  should  be  examined,  in  order  to  ascertain  its  richness 
and  quantity,  and  whether  it  contains  colostrum.  If  there  is  colos- 
trum after  the  eighth  day,  it  is  probable  that  there  is  some  fault  in 
the  health  or  digestion  of  the  wet-nurse,  and  that  her  milk  may 
disagree  with  the  infant.  It  is  not  necessary  that  the  breasts  should 
be  large,  in  order  to  furnish  a  sufficient  quantity  of  milk,  since,  as 
has  been  already  stated,  in  some  the  secretory  function  is  active 
during  the  time  of  each  nursing,  so  that,  although  the  breasts  are 
of  moderate  size,  a  sufficient  amount  of  milk  is  furnished.  The 
nipples  should  be  well  formed  and  prominent,  and  preference  is  to 
be  given  to  those  wet-nurses  in  whom  vessels  are  seen  ramifying 
over  the  breasts. 

By  examination  of  the  milk,  its  degree  of  richness  can  be  readily 
ascertained.  A  quantity  of  it  should  be  placed  in  a  test-tube,  and 
the  cream,  which  rises  to  the  top,  indicates,  approximatively,  the 
character  of  the  milk.  Good  milk  furnishes  three  per  cent,  of 
cream,  and  the  caseum  and  sugar  usually  correspond  in  quantity 
with  the  cream.  An  instrument  has  been  invented,  called  the 
lactometer,  by  which  the  exact  amount  of  the  cream  can  be  ascer- 
tained. It  is  simply  a  tube  graded  into  100  divisions.  It  is  placed 
upright,  and  filled  with  milk,  and  the  number  of  divisions  occupied 
by  the  cream  indicates  its  proportion  in  100  parts.  The  lactoscope 
is  another  instrument  employed  for  the  purpose  of  ascertaining  the 
richness  of  the  milk.  It  consists  of  two  concentric  tubes,  which 
move  upon  each  other.  Milk  which  we  wish  to  examine  is  poured 
within  the  tubes  sufficient  to  obscure  a  light  viewed  through  it, 
three  feet  distant.  The  column  of  milk  is  then  diminished,  till 
the  lio;ht  beo-ins  to  be  visible.  The  size  of  the  column  indicates 
the  degree  of  opacity  and  the  richness.  The  lactoscope  was  in- 
vented by  M.  Donne,  and  is  described  by  him. 

Dr.  Minchin  recommends  a  simple  mode  of  determining  the 
richness  of  cow's  milk,  and  it  would  equally  answer  for  the  breast 
milk.  A  vessel  holding  about  one  ounce,  and  containing  a  gradu- 
ated enamel  slab,  passing  diagonally  from  above  downwards,  is  filled 
with  milk.     It  is  then  covered  with  a  glass  slide  carried  over  it  in 


52  SELECTION    OF    A    WET-NUESE. 

sucli  a  way  as  to  exclude  bubbles.  The  number  of  degrees  which 
can  be  read,  indicates  the  character  of  the  milk,  as  regards  its 
richness. 

Examination  of  the  milk  with  the  microscope  not  only  enables 
us  to  determine  whether  there  are  abnormal  corpuscles  or  granular 
elements,  but  also  its  richness.  It  should  be  examined  before  the 
cream  has  separated.  Oil  globules  of  small  size,  and  few,  indicate 
poverty  of  the  milk ;  very  large  oil  globules  are  said  to  indicate 
milk  which  is  apt  to  be  indigestible,  especially  in  feeble  infants. 
Such  are  the  free  globules  of  the  colostrum.  Numerous  oil  globules 
of  medium  size  indicate  nutritious  milk.  Yogel,  in  1850,  made  the 
discovery  of  vibriones  in  human  milk.  The  fact  is  established  that 
these  animalcules  may  be  generated  in  the  milk  within  the  breast, 
though  such  cases  are  not  frequent.  Dr.  Gibb  describes  a  case  which 
he  met.  {Ranking' s  Abstract^  vol.  xxxiv.)  An  infant,  7  weeks  old, 
wet-nursed  by  its  mother,  who  had  the  appearance  of  perfect  health, 
was,  nevertheless,  ill-nourished  and  emaciated.  It  had  no  diarrhoea 
or  other  apparent  disease,  and  the  milk  was  therefore  examined. 
Vibriones  baculi  were  found  in  the  milk  immediately  after  it  was 
obtained  from  the  breast.  The  milk  had  the  usual  amount  of 
cream,  and  seemed  to  the  naked  eye  of  good  quality.  According 
to  Dr.  Gibb,  two  genera  of  animalcules  occur  in  the  milk,  namely, 
vibriones  and  monads.  It  is  believed  that  the  monads  occur  in 
consequence  of  fermentation  of  the  sugar  and  the  production  of 
lactic  acid.  Vogel  also  attributed  the  production  of  the  vibriones 
to  fermentation  occurring  in  consequence  of  heat  and  congestion 
of  the  breast,  connected  with  sexual  excitement.  This  explanation 
is  probably  not  correct,  because  vibriones  sometimes  occur  when 
there  is  no  unusual  heat  of  ln'east,and  no  evidence  of  fermentation. 
The  fact  that  such  organisms  may  occur  in  milk  which  seems  of 
good  quality  to  the  naked  eye,  affords  additional  proof  of  the  use- 
fulness of  the  microscope  in  the  selection  of  a  wet-nurse. 

Many  wet-nurses  have  a  return  of  the  menses  as  early  as  the 
fourth  or  fifth  month  after  delivery.  The  re-establishment  of  this 
function  in  some  women  impairs  the  quality  of  the  milk,  so  as  to 
render  it  less  nutritious,  and  jDcrhaps  less  digestible;  in  other  women 
it  does  not  sensibly  affect  the  character  of  the  fluid  or  its  quantity. 
In  the  selection  of  a  wet-nurse,  then,  preference  should  be  given  to 
one  who  does  not  have  the  periodical  sickness,  but  if  she  is  already 
employed,  and  gives  satisfaction,  the  reappearance  of  the  catamenia 
does  not  indicate  the  need  of  a  change  of  nurse,  unless  the  diges- 
tion of  the  infant  is  disordered,  or  its  nutrition  is  impaired. 


EXAMINATION    OF    THE    MILK.  53 

In  the  selection  of  a  wet-nurse  attention  sliould  also  be  given  to 
her  mental  and  moral  traits.  Cheerfulness,  affection,  veracity,  and 
a  proper  appreciation  of  the  resi^onsibility  of  her  situation  enhance 
greatly  the  value  of  a  wet-nurse.  Not  less  important  are  habits  of 
temperance  and  cleanliness.  I  could  cite  cases  of  the  most  melan- 
choly results  from  the  absence  of  these  traits.  In  one  case  idiocy 
resulted  from  an  infant  falling  upon  the  pavement  from  the  arms 
of  a  reckless  or  intemperate  wet-nurse. 

In  most  cases  the  mode  of  examination  indicated  above  suffices 
to  show  the  character  of  a  wet-nurse,  so  far  as  her  health  and  milk 
are  concerned.  It  should  be  borne  in  mind,  however,  that  the 
microscope  does  not  always  reveal  deleterious  properties  in  the 
milk.  Elements  which  are  in  a  state  of  solution,  and  are  invisible, 
may  occur  in  excess,  so  as  to  impair  the  quality  of  the  milk,  and 
render  it  indigestible.  The  following  case,  in  which  the  saline 
ingredients  seem  to  have  been  in  excess,  is  related  by  Dr.  Ilartmann 
{British  and  Foreign  Medical  Review^  vol.  xii.) :  "An  infant  whose 
mother  was  in  good  health,  and  had  borne  several  children,  exhibited 
a  healthy  appearance  for  the  first  five  weeks  after  birth.  The  alvine 
evacuations  then  became  copious,  fluid,  and  discolored,  and  the 
child  lost  flesh  and  streno-th.  After  the  usual  remedies  had  been 
vainly  administered  for  a  fortnight,  the  mother  remarked  that  the 
child  did  not  take  the  right  breast  willingly,  and  so  much  did 
the  unwillingness  increase,  that  at  length  the  mere  application  of 
the  nipple  to  the  child's  lips  occasioned  loud  crying.  On  exami- 
nation it  was  found  that  the  milk  of  the  right  breast  had  a  dis- 
tinctly saline  taste ;  whereas  the  milk  of  the  opposite  breast  was 
of  the  ordinary  sweetness ;  no  difference  of  consistence  or  color 
was  discoverable.  From  that  time  the  child  was  only  allowed  to 
nurse  the  left  breast,  and  in  a  few  days  all  diarrhoea  and  sickliness 
of  appearance  vanished."  In  this  case  there  was  no  appreciable 
disease  of  the  breast,  although  its  secretion  was  perverted.  The 
deleterious  character  of  the  milk  was  discovered,  not  by  any  change 
in  its  appearance,  but  by  the  taste. 


54  COURSE    OF    LACTATION  —  WEANIXG. 


CHAPTER  YI. 

COURSE  OF  LACTATION— WEANING. 

Regularity  in  nursing  is  required.  The  young  infant  in  whom 
the  milk  is  rapidly  assimilated,  may  take  the  breast  every  two  hours 
in  the  day,  and  two  or  three  times  in  the  night.  Still,  as  M.  Donne 
has  said,  mathematical  exactness  in  this  matter  would  he  ridiculous. 
Quiet,  natural  sleep  of  a  well-nourished  infant  should  not  be  inter- 
rupted in  order  to  give  it  the  breast,  unless  the  sleep  be  unusually 
protracted.  It  will  usually  awaken  when  the  system  requires  more 
nutriment.  Ill-nourished  infants,  according  to  my  observations, 
sleep  but  little  until  they  become  much  prostrated,  when  they  are 
drowsy,  in  consequence  of  passive  congestion  of  the  brain.  This 
drowsiness  is  evidently  a  pathological  symptom.  It  shows  the  need 
of  increased  nutrition.  It  is  due  to  scantiness  of  milk,  or  milk  of 
poor  quality,  and  the  infant  should  be  aroused  frequently  for  the 
purpose  of  giving  it  nutriment  or  even  stimulants. 

As  the  infant  grows  older  the  stomach  receives  a  larger  amount 
of  milk,  and  it  should  nurse  less  frequently.  The  breast  milk  is 
sufficient  for  its  nutrition  till  the  age  of  six  or  eight  mouths,  pro- 
vided it  is  abundant  and  of  good  quality.  If  the  mother  is  strong 
and  experiences  no  exhaustion  from  suckling,  the  infant,  therefore, 
need  receive  no  other  nutriment  till  that  age,  or  indeed  till  the  age 
of  ten  or  twelve  months. 

Many  mothers,  however,  by  the  third  or  fourth  month  of  lacta- 
tion find  that  they  have  not  sufficient  milk  to  meet  the  wants  of 
the  infant.  The  constant  drain  upon  their  systems  sensibly  impairs 
their  health.  In  such  cases  it  is  proj)er  to  commence  with  kittle 
feeding  from  the  spoon  or  bottle,  and  increase  the  quantity  given 
as  the  infant  grows  older.  Great  care  is,  however,  requisite  in  the 
preparation  of  food  for  so  young  an  infant,  whose  digestive  organs 
are  still  feeble  and  easily  deranged.  In  the  country,  where  diar- 
rhoeal  affections  and  the  so-called  gastric  derangements  are  not  fre- 
quent, the  danger  from  artificial  feeding  is  less  than  in  the  city, 
and  in  the  cool  months  in  the  city  the  danger  is  less  than  in  the 
summer  season.     Infants  of  the  city,  between  the  months  of  May 


COURSE    OF    LACTATION  —  WEANIXG.  55 

and  October,  have  a  strong  predisposition  to  diarrhoeal  attacks,  the 
result  of  anti-hygienic  influences  wliich  surround  them.  Errors  of 
diet  in  their  case  readily  provoke  disease  or  derangement  of  the 
digestive  organs,  often  of  a  severe  and  dangerous  form.  Moreover, 
experience  has  shown  that  these  infants,  if  fed  with  the  bottle, 
however  carefully,  during  the  period  when  nature  designed  that 
they  should  be  nourished  by  lactation,  very  commonly  are  affected 
in  the  hot  months  with  more  or  less  vomiting  and  diarrhoea,  fol- 
lowed by  emaciation  and  other  evidences  of  mal-nutrition.  There- 
fore, an  exception  must  be  made  in  case  of  the  city  infant  as  regards 
the  commencement  of  artificial  feeding.  If  it  is  under  the  age  of 
one  year,  it  should  be  nourished  exclusively,  or  almost  exclusively, 
at  the  breast  during  the  hot  months,  when  practicable,  even  if  the 
mother  suffers  somewhat  in  her  health  from  the  constant  drain 
upon  her  system.  The  infant  should,  however,  receive  the  amount 
of  nutriment  which  it  requires,  and,  if  there  is  not  sufficient 
breast  milk,  it  will  be  necessary  to  supply  the  deficiency  by  arti- 
ficial feeding. 

The  subject  of  artificial  feeding  will  engage  our  attention  in  a 
separate  chapter.  It  suffices,  therefore,  in  this  connection  to  state 
that  nursing  infants  of  three  or  four  months  may  begin  to  take  a 
little  cow's  milk,  carefully  prepared  and  of  the  best  quality.  It 
should  be  diluted,  but  the  amount  of  dilution  required  obviously 
depends  on  the  richness  of  the  milk.  Rich  country  milk  is  suffi- 
ciently diluted,  if  the  infant  is  in  good  health,  by  adding  half  its 
quantity  of  water,  while  most  samples  of  milk  furnished  in  the 
city  do  not  require  more  than  one-third  their  quantity  of  water. 

A  little  sugar  of  milk,  which  is  slowly  soluble,  should  be  dis- 
solved in  the  water  before  its  mixture  with  the  milk.  One  drachm 
of  the  sugar  is  sufficient  for  five  or  six  ounces  of  the  milk,  and  to 
the  same  quantity,  if  the  stools  are  at  all  acid,  two  teaspoonfuls  of 
lime-water  should  be  added.  An  alkali  taken  with  cow's  milk 
retards  the  coagulation  of  casein  in  the  stomach,  and  tends  to  pre- 
vent the  formation  of  a  large,  thick  curd  in  the  stomach,  which  is 
with  difficulty  digested.  If,  therefore,  the  child  vomits  such  curds, 
or  passes  fragments  of  them  in  the  stools,  a  larger  proportion  of 
lime-water  may  be  added,  or  the  carbonate  of  soda  as  recommended 
by  Vogel,  who  dissolves  one  drachm  of  the  carbonate  in  six  ounces 
of  water,  and  adds  a  teaspoonful  to  the  milk  at  each  meal.  It  is 
proper,  also,  to  allow  farinaceous  food  to  an  infant  of  three  or  four 
months,  if  its  digestive '  organs  are  in  good  condition.  I  prefer 
barley  flour  for  this  purpose  to  arrowroot,  rice,  or  wheat  flour. 


56  COURSE    OF    LACTATION  —  WEANING. 

Barley-water  should  be  jirepared  from  Robinson's  or  some  other 
flour  of  good  qualit}^,  and  mixed  while  still  warm  with  an  equal 
quantity  of  milk,  and  the  sugar  of  milk  added.  The  barley-water 
should  be  of  about  the  consistence  of  milk,  and  prepared  in  the 
usual  way  by  boiling.  The  milk  should  not  be  boiled.  It  may, 
indeed,  be  stated,  as  a  rule,  that  it  is  not  advisable  to  boil  milk 
designed  for  infants,  except  in  the  city,  where  it  may  be  boiled  in 
order  to  its  better  preservation.  Toast-water  may  be  also  employed 
for  diluting  the  milk,  but  it  is  less  nutritious  than  barley-water. 
At  the  age  of  six  months,  if  the  infant  is  in  good  condition,  the 
milk  need  not  be  diluted. 

As  the  infant  grows  older,  semi-liquid  food  may  be  given.  Pap 
prepared  with  stale  bread,  or  a  rolled  soda-cracker,  may  now  be 
given,  once  or  twice  daily,  between  the  times  of  nureing,  and  occa- 
sionally beef-tea  or  chicken-broth,  thickened  with  cracker  or  bread, 
is  taken  with  relish,  and  if  well  prepared,  and  given  no  oftener 
than  once  or  twice  a  day,  it  is  commonly  readily  digested,  while  it 
is  highly  nutritious.  If  the  quantity  of  breast  milk  diminishes, 
as  it  often  does,  towards  the  close  of  the  first  year,  artificial  food 
should  be  given  oftener,  so  as  to  supply  the  deficiency.  Solid  food 
requires  considerable  development  of  the  digestive  organs  for  its 
ready  assimilation.  It  should  not,  therefore,  be  given  till  the  close, 
or  near  the  close,  of  the  first  year. 

"Weaning  ought  to  take  place,  as  a  rule,  between  the  ages  of 
twelve  and  eighteen  months.  It  is  well,  if  the  mother's  health  is 
good,  and  her  milk  is  sufficient,  to  defer  weaning  till  the  canine 
teeth  appear.  The  infant  then,  possessing  sixteen  teeth,  is  able  to 
masticate  the  softer  kinds  of  solid  food.  Weaning  should  be  gra- 
dual. ]\Iothers  often  speak  of  weaning  on  a  certain  day.  They 
have  given  but  little  artificial  food,  and  have  suckled  at  regular 
intervals,  till  at  a  fixed  time  they  have  denied  the  breast  altogether. 
This  abrupt  change  of  diet  should  be  discouraged.  It  should  only 
be  recommended  under  peculiar  circumstances.  It  is  apt  to  derange 
the  digestive  organs,  and  it  causes  fretfulness  and  sleeplessness  on 
the  part  of  the  infant  for  a  week  or  more.  Weaning  should  com- 
mence by  feeding  with  the  spoon,  a  little  oftener  through  the  day, 
and  nursing  less,  and  by  discontinuing  the  practice  of  suckling  at 
night.  The  infant  tolerates  this  gradual  change  of  diet,  while  it 
rebels  against  sudden  weaning,  and  by  its  fretfulness  increases 
greatly  the  care  and  trouble  of  the  mother.  The  infant  in  the 
city  should  not  be  weaned  in  warm  weather,  nor  within  a  month 
immediately  preceding  it.    If  the  mother's  health  fails  or  her  milk 


ARTIFICIAL    FEEDING.  67 

becomes  deficient,  in  the  summer  months,  so  that  she  cannot  con- 
tinue suckling,  the  infant  should  bo  sent  immediately  to  the  coun- 
try, or  a  wet-nurse  be  employed.  Many  infants  are  sacrificed  in 
consequence  of  ignorance  of  the  danger  of  weaning  under  the  cir- 
cumstances mentioned.  Severe  diarrhoea,  inflammatory  or  non- 
inflammatory, is  apt  to  result.  This  subject  will  be  considered 
elsewhere. 


CHAPTER   VII. 

ARTIFICIAL  FEEDING. 

Occasionally  the  mother  is  unable  to  suckle  her  infant,  and  a 
hired  wet-nurse  cannot  be  or  is  not  obtained.  Artificial  feeding  is 
then  necessary.  In  the  large  cities,  if  I  may  judge  from  our  iSTew 
York  experience,  this  mode  of  alimentation  for  young  infants 
should  always  be  discouraged.  It  generally  ends  in  death,  pre- 
ceded by  evidences  of  faulty  nutrition.  A  considerable  proportion 
of  those  nourished  in  this  manner  thrive  during  the  cool  months, 
but  on  the  approach  of  the  warm  season  they  are  the  first  to  be 
aftected  with  diarrhoea  and  other  symptoms  indicating  derange- 
ment of  the  digestive  function.  In  my  opinion,  based  on  a  pretty 
extended  observation,  more  than  half  of  the  ]^ew  York  spoon-fed 
infants,  who  enter  the  summer  months,  die  before  the  return  of  cool 
weather,  unless  saved  by  removal  to  the  country.  In  the  country, 
and  in  the  small  inland  cities,  the  results  of  artificial  feeding  are 
much  more  favorable.  The  majority  live,  and  in  elevated  farming 
sections,  on  account  of  the  salubrity  of  the  air,  and  the  facility 
with  which  milk,  fresh  and  of  the  best  quality,  is  obtained,  arti- 
ficial feeding  appears  to  be  nearly  as  favorable  as  wet-nursing. 

Young  infants,  fed  by  the  hand,  obviously  require  food  prepared 
so  as  to  resemble  as  closely  as  possible  the  human  milk.  The 
basis  of  such  food  must,  therefore,  be  the  milk  of  some  animal. 
The  following  table,  prepared  by  MM.  Yernois  and  Becquerel, 
gives  the  proportion  of  the  ingredients  of  human  milk,  and  the 
milk  of  the  four  domestic  animals  which  is  most  easily  obtained 
and  most  frequently  employed  as  food. 


58 


ARTIFICIAL    FEEDING. 


Composition  of  Milk. 


Specific 

gravity. 

100  parts 

contain — 

The  solid  corapoi 

lents  consist  of — 

Fluids. 

Solids. 

Sugar. 

Butter. 

Casein  and 

extractive 

matters. 

Sails. 

Man 

1032.67 
1033.38 
1034.57 
1033.53 
1040.98 

889.08 

864.06 
890.12 
844.90 
832.33 

110.92 
135.94 
109.88 
155.10 
167.68 

43.64 
38.03 
50.46 
36.91 
39.43 

26.66 
36.12 

18.53 
56.87 
54.31 

39.24 

55.15 
35.65 
55.14 
69.78 

1.38 

Cow 

6.64 

Ass 

5.34 

Goat 

6.18 

Ewe 

7.16 

Cow's  milk  is  most  readily  obtained,  and  is  commonly  used  as  a 
substitute  for  human  milk,  compared  with  which  it  contains  less 
water  and  sugar,  but  more  butter,  casein,  and  salts.  Its  composi- 
tion, however,  varies  considerably  according  to  the  food  of  the  cow 
and  other  circumstances.  The  variations  in  the  milk  of  the  cow, 
according  to  the  nature  of  its  food,  have  been  considered  in  a  pre- 
ceding chapter.  It  has  been  stated,  also,  that  the  milk  first  obtained 
in  milking  is  most  watery,  since  it  is  longer  secreted  than  the  last 
milk,  or  the  "stripping."  The  stall-fed  cow  gives  acid  milk,  while 
the  cow  grazing  in  a  pasture  gives  milk  that  is  alkaline.  Again, 
the  milk  in  the  first  months  after  calving  is  richer  than  after  the 
lapse  of  several  months. 

It  is  obvious  from  the  above  facts  that  the  analysis  of  difierent 
specimens  of  cow's  milk  must  dififer  greatly,  and  the  same  is  true 
of  the  milk  of  the  goat  and  ass,  and  probably  of  the  ewe.  In  fact, 
difierent  samples  of  the  milk  of  the  same  animal  may  difier  more 
from  each  other,  in  their  chemical  character,  thaix.the  average  milk 
of  one  animal  from  that  of  another. 

The  milk  of  the  goat  and  that  of  the  ass  have  been  recommended 
as  food  for  infants  in  preference  to  cow's  milk,  on  the  ground,  as 
is  alleged,  that  they  more  nearly  resemble  himian  milk.  But  by 
reference  to  the  foregoing  table  it  will  be  seen  that  more  impor- 
tance has  been  attached  to  this  supposed  resemblance  than  the  facts 
justified.  Neither  the  milk  of  the  ass  nor  goat,  so  far  as  its  chemi- 
cal character  is  concerned,  would  seem  to  possess  any  advantages 
over  cow's  milk.  The  ass's  milk  is  procured  with  difiiculty,  and 
is  seldom  used.  An  objection  to  goat's  milk  is  the  unpleasant  odor 
which  it  often  possesses,  due  to  the  presence  of  hircic  acid.  It  is 
stated,  however,  by  Parmentier,  that  this  odor  is  only  noticed  in 
tlie  milk  of  goats  that  have  horns.  An  important  advantage, 
in  the  city,  in  the  use  of  goat's  milk,  is  that  the  animal  can  be 


ARTIFICIAL    FEEDING.  59 

kept  at  little  expense,  so  that  even  poor  families  who  are  not  able 
to  purchase  and  feed  a  cow  can  generally  possess  a  goat,  from  which 
fresh  milk  can  be  obtained  at  any  time.  Preference  is  to  be  given 
to  goat's  milk  when  fresh,  over  cow's  milk  brought  from  the 
country,  perhaps  watered  on  the  way,  and  several  hours  old  when 
received.  If,  however,  as  both  chemical  analysis  and  experience 
show,  goat's  milk  is  no  better  as  food  for  infants  than  cow's  milk 
when  fresh  and  from  healthy  cows,  the  latter  must  continue  in 
common  use  for  this  purpose. 

Milk  used  for  infants  should  always  be  alkaline.  If  it  is  acid, 
as  shown  by  the  proper  test,  it  should  be  rejected;  or,  if  there  is 
none  better,  should  be  rendered  alkaline  by  the  addition  of  lime- 
water  or  carbonate  of  soda.  The  nurse  should  test  the  milk  at 
different  periods  through  the  day,  and  be  taught  to  make  the 
necessary  addition.  M.  Donn^  prefers  the  first  milking,  when  it 
is  possible  to  obtain  it.  This  contains  a  smaller  proportion  of  solid 
elements  than  the  average  milk,  bears  a  closer  resemblance  in  its 
chemical  character  to  human  milk,  and  requires  but  little  dilution. 
The  upper  third  of  the  milk,  after  it  has  stood  two  or  three  hours, 
is  also  preferable,  as  the  casein,  which  is  digested  with  more  diffi- 
culty than  the  other  elements,  has  a  high  specific  gravity  and  tends 
to  settle  towards  the  bottom.  If  the  infant  is  under  the  age  of 
two  or  three  months,  the  milk  should  be  diluted  with  one-third 
or  one-half  its  quantity  of  water.  After  the  age  of  three  or  four 
months,  it  requires  no  dilution.  It  should  always  be  given  at 
a  uniform  temperature,  namely,  a  little  warmer  than  the  body. 
Employed  habitually  too  hot  or  too  cold,  it  is  apt  to  cause  stoma- 
titis, if  not  more  serious  disease  of  the  digestive  organs. 

After  the  fourth  month,  the  infant  may  be  allowed  crushed  soda 
cracker,  or  stale  bread  upon  which  boiling  water  is  poured  and 
then  drained  off,  and  afterwards  milk  added.  Porridge  made  with 
rice,  barley  flour,  or  arrowroot  is  also  a  proper  article  of  diet  at 
this  age.  After  the  fifth  or  sixth  month,  milk  with  crumbled  soda 
cracker  or  stale  bread  may  also  be  allowed. 

The  shops  contain  various  preparations  of  food  for  infants,  and 
most  of  them  have  been  employed  in  the  institutions  of  this  city 
sufficiently  to  ascertain  their  effects.  The  one  which  has  given 
most  satisfaction  is  known  as  IsTestle's  Lacteous  Farina,  prepared 
by  Henri  Nestle,  a  Swiss  chemist.  It  is  preferred  in  the  IN'ursery 
and  Child's  Hospital,  and  Infant's  Hospital,  to  Liebig's  Soup,  but 
the  latter,  so  highly  extolled  by  the  German  physicians,  and  a 
description  of  which  will  be  found  in  the  appendix,  may  not  have 


60  BATHS  —  CLOTHING. 

been  well  prepared  in  these  institutions.  ISTestle's  food  is,  however, 
expensive,  and  althongh  infants  thrive  well  on  it  in  the  cooler 
months,  I  am  of  opinion,  from  my  own  observations,  that  in  the 
hottest  weather,  when  diarrhceal  aifections  are  so  prevalent  and 
fatal,  it  has  too  laxative  an  effect.  I  do  not,  therefore,  recommend 
as  the  ordinary  diet  of  healthy  infants  any  other  food  than  the 
mother  is  able  to  prepare  readily,  with  milk,  or,  under  certain  cir- 
cumstances, barley-water,  as  its  basis. 

In  the  first  half  year  it  is  most  convenient  and  otherwise  prefer- 
able to  give  the  food  through  a  sucking-bottle,  after  which  the 
infant  may  be  fed  with  a  spoon,  or  taught  to  drink  from  a  cup. 
The  physician  should  positively  forbid  the  use  of  sugar  teats  and 
various  sweetened  admixtures  which  nurses  are  so  apt  to  em- 
ploy, as  they  tend  to  produce  simple  stomatitis,  sprue,  and,  if  much 
employed,  even  indigestion  and  diarrhoea. 

Between  the  ages  of  one  and  two  years  the  teeth  have  become 
sufiiciently  developed  for  the  mastication  of  light  food.  Tender 
and  finely  cut  meat,  potato  baked  and  mashed,  bread  and  butter, 
and  even  certain  fruits  carefully  selected,  may  then  be  allowed. 
After  the  age  of  two  years  less  rigid  surveillance  of  the  food  is 
required,  but  the  variety  is  sufiicient  if  all  dishes  except  the  most 
bland  and  unirritating  are  excluded  till  after  the  first  years  of 
childhood.  The  reader  is  referred  to  Appendix  A  for  various 
dietary  formulae  and  directions  relating  to  the  choice  and  prepara- 
tion of  food,  which  will  be  found  useful  in  the  treatment  of  young 
children,  in  those  diseases  especially  in  which  the  digestive  func- 
tion is  seriously  impaired. 


CHAPTER    YIII. 

BATHS— CLOTHING. 

Daily  ablution  of  the  infant  conduces  to  its  comfort  and  health. 
If  under  the  age  of  two  months,  it  should  be  bathed  daily  in  water 
of  about  the  temperature  of  92°.  As  it  grows  older  the  tempera- 
ture should  be  gradually  reduced,  a  bath  at  88°  to  90°  being  proper 
for  an  infant  between  the  ages  of  three  and  six  months,  and  one  at 
86°  for  an  infant  between  six  and  twelve  months.  In  the  second 
and  third  years  the  temperature  of  the  bath  should  be  about  84°. 
After  the  bath,  which  should  continue  from  five  to  ten  minutes, 


BATHS  —  CLOTHING.  61 

the  surface  should  be  gently  rubbed  with  a  soft  towel  to  produce 
reaction  and  a  glow  of  the  skin,  which  would  prevent  danger  of 
taking  cold. 

The  clothing  of  children,  especially  in  our  variable  climate  of 
the  north,  is  a  matter  of  importance,  and  one  in  regard  to  which 
the  parents  often  require  instruction.  It  may  be  stated,  as  a  rule, 
that  the  chest  and  abdomen  of  the  infant  should  be  so  covered  with 
flannel  that  there  is  no  danger  of  producing  chilliness  by  a  sudden 
reduction  of  the  external  temperature  or  exposure  to  a  current  of  air. 
By  this  precaution  many  cases  of  laryngitis,  bronchitis,  and  diar- 
rhoeal  affections,  now  so  common  in  infancy,  might  be  avoided.  In 
winter  the  flannel  should  be  thick,  and  in  the  summer  thin.  Even 
in  the  hottest  weather  the  abdomen  should  have  a  light  flannel 
covering,  which  increases  the  comfort,  if  the  surface  is  in  the  nor- 
mal state.  If  lichen,  which  is  not  uncommon  in  the  warm  months, 
appear  upon  the  surface,  I  would  not  remove  the  flannel,  but  place 
under  it  linen  or  soft  muslin. 

The  popular  idea  that  children  may  be  hardened  by  exposure 
to  the  weather  in  scanty  clothing,  and  by  being  bathed,  even  at 
the  most  tender  age,  in  water  at  so  low  a  temperature  as  to  pro- 
duce chilliness,  cannot  be  too  strongly  combated.  The  hygienic 
management  of  the  child  should  always  be  such  as  insures  present 
comfort.  If  it  do  not,  if  it  is  regarded  with  aversion  and  dread 
by  the  child,  the  me1,hod  is  wrong. 

The  dress  should  always  be  so  loose  as  to  allow  free  movements, 
and  not  embarrass  in  the  least  any  of  the  functions.  This  is  a 
matter  which  is  left  too  much  to  the  discretion  and  intelligence  of 
the  nurse,  who  is  usually  so  ignorant  of  the  important  facts  in 
physiology  that  she  unwittingly,  and  with  the  best  intentions,  in- 
jures her  charge.  I  have  often  interposed  to  loosen  the  dress  of  the 
new-born,  which  was  so  tight  as  to  sensibly  embarrass  respiration ; 
and  one  case  has  been  reported  to  me  in  which  it  appeared  that 
death  resulted  from  this  cause.  Infants,  especially,  who  are  so 
liable  to  pulmonary  collapse  and  intestinal  hernias,  should  have 
loose  covering  of  both  chest  and  abdomen. 

The  feet  of  children  should  always  be  warm.  Infants  require 
flannel  stockings,  thick  or  thin,  according  to  the  season  Care 
should  be  taken  that  the  shoes  produce  no  compression,  and  they 
should  be  exchanged  for  those  of  a  larger  size  as  often  as  is  required 
by  the  growth  of  the  feet.  Deformity  of  the  feet  or  toes,  ingrow- 
ing toe-nail,  and  induration  of  the  skin,  can  sometimes  be  traced 
back  to  tightness  of  a  shoe  in  childhood. 


62       ACCIDENTS    AND    AILMENTS    INCIDENTAL    TO    INFANTS. 

Physicians  are  so  well  aware  of  the  importance  of  domiciliary 
cleanliness  and  ventilation,  of  the  free  admission  into  the  nursery 
of  solar  light,  and  of  the  importance  of  out-door  exercise  as  a 
means  of  invigorating  the  system  and  promoting  healthy  func- 
tional activity,  that  nothing  need  be  stated  in  reference  to  these 
subjects  in  this  connection. 


CHAPTER   IX. 

ACCIDENTS  AND  AILMENTS  INCIDENTAL  TO  THE  BIRTH  OF 
THE  INFANT,  AND  DETACHMENT  OF  THE  CORD. 

Apnoea  (Asphyxia)  Neonatorum. 

In  the  healthy  infant,  born  under  favorable  circumstances,  the 
two  important  functions  of  life,  respiration  and  circulation,  are 
established  within  the  first  minute.  But  it  not  infrequently  hap- 
pens, in  consequence  of  some  unfavorable  circumstance,  that  the 
heart  and  lungs  fail  to  act,  and  the  infant  lies  motionless  as  one 
dead.  Sometimes  in  these  cases  an  occasional  pulsation  of  the 
heart  can  be  detected  when  the  fingers  press  under  the  left  ribs, 
but  there  is  no  respiration.  According  to  the  nature  of  the  cause, 
the  surface  is  exsanguine  or  cyanotic  and  livid. 

Causes. — These  are  various.  The  fault  may  be  partly  in  the 
infant ;  it  may  be  feeble  in  its  development ;  but  the  common  causes 
are  compression  of  the  cord  during  birth,  from  breech  presentation 
or  otherwise,  powerful,  frequent,  and  long-continued  uterine  con- 
tractions, often  induced  by  ergot,  but  sometimes  occurring  nor- 
mally, which  compress  the  placenta,  and  consequently  obstruct  the 
fcetal  circulation ;  detachment  of  the  placenta  before  birth,  and 
protracted  labor,  from  pelvic  malformation  or  otherwise,  even  when 
there  is  no  unusual  severity  of  the  pains. 

Tkeatment. — Obviously  the  treatment  must  be  prompt.  Mucus 
should  be  removed  from  the  mouth  and  fauces  with  the  finger, 
and,  except  in  those  cases  in  which  there  has  been  placental  hem- 
orrhage or  anaemia  from  other  causes,  as  exhibited  by  pallor  of  the 
surface,  a  few  drops  of  blood  should  be  allowed  to  run  from  the 
cut  extremity  of  the  cord.  The  flow  induced  aids  in  establishing 
the  circulation,  and,  in  the  large  proportion  of  cases  in  which  there 
is  congestion  of  internal  organs,  gives  partial  relief  to  it.  Brisk 
rubbing  of  the  body,  slapping  the  buttocks,  blowing  in  the  face. 


APNCEA    NEONATORUM.  63 

sprinkling  water  upon  it,  alternately  transferring  the  body  from  a 
tub  of  hot  to  cold  water  may  be  tried  in  quick  succession,  and,  if 
there  are  no  signs  of  returning  animation,  no  time  should  be  lost 
in  resorting  to  artificial  respiration. 

The  child  should  be  placed  on  its  side  upon  the  edge  of  a  table, 
with  a  blanket  underneath  it,  and  the  head  in  such  a  position  that 
the  epiglottis  falls  forward ;  a  towel  or  napkin  should  be  placed 
over  its  face,  having  a  hole  of  sufficient  size  to  blow  through  cor- 
responding with  its  mouth.  The  physician  compressing  firmly  the 
epigastrium  with  his  thumb,  blows  a  full  breath  through  the  hole. 
A  little  of  the  air,  notwithstanding  the  compression,  enters  the 
stomach,  some  may  escape  by  the  nostrils,  and  the  rest  enters  the 
lungs.  Immediately,  the  hand  passing  from  the  ej^igastrium  to  the 
thorax,  compresses  it  gently  though  with  sufficient  force  to  produce 
expiration.  This  should  be  repeated  six  or  eight  times  per  minute. 
The  action  of  the  heart,  previously  slow,  becomes  quicker  by  the 
artificial  respiration,  and  I  am  confident  that  I  have  been  able  to 
produce  pulsations  by  this  method  when  the  heart  had  ceased  to 
beat,  and  death,  to  all  appearance,  had  occurred.  Some  recom- 
mend placing  the  infant  on  the  right  side,  on  account  of  the  posi- 
tion of  the  valve  between  the  auricles,  but  I  think  it  is  better  to 
change  it  from  one  side  to  the  other,  in  order  to  prevent  conges- 
tions, which  are  so  apt  to  occur  when  the  circulation  is  imperfect. 
The  circulation  always  commences  sooner  than  respiration.  The 
first  respirations  are  mere  gasps,  not  more  than  one  or  two  per 
minute  in  cases  of  decided  asphyxia,  but  as  they  become  more 
frequent  they  are  also  deeper. 

Artificial  respiration  should  be  continued  ten  or  fifteen  minutes 
in  cases  in  which  no  action  of  the  heart  can  be  detected  by  pressing 
the  fingers  under  the  ribs,  when,  if  there  are  no  signs  of  returning 
animation,  the  case  is  hopeless.  If  there  is  any  pulsation,  how- 
ever feeble,  we  should  not  cease  in  the  attempt  at  resuscitation. 
Some  prefer  insuffiation  through  a  tube  (as  the  segment  of  a  catheter) 
introduced  into  the  larynx,  and  pressure  upon  the  thyroid  carti- 
lage so  as  to  close  the  pharynx,  instead  of  upon  the  epigastrium. 
The  principle  of  treatment  is  similar,  but  the  mode  which  I  have 
recommended  above  I  have  found  successful  beyond  expectation. 
Thus,  in  one  case  in  my  practice  in  which  pulsation  in  the  um- 
bilical cord  had  ceased  from  ten  to  fifteen  minutes  before  birth 
in  consequence  of  its  prolapse,  I  employed  artificial  respiration 
nearly  a  quarter  of  an  hour  before  there  was  any  appreciable  pul- 
sation, but  by  perseverance  the  circulatory  and  respiratory  func- 


64       ACCIDENTS    AND    AILMENTS    INCIDENTAL    TO    INFANTS. 

tions  were  fully  re-established,  and  the  child  lived  and  was  vigorous. 
When  respiration  commences  insufflation  may  cease,  but  it  is  pro- 
per to  aid  the  respiratory  movements  a  little  longer  by  compress- 
ing the  thorax  after  each  inspiration.  Still,  the  physician  may 
be  disappointed  in  the  result.  In  not  a  small  proportion  of  cases 
the  respiration  continues  gasping,  and  after  a  few  hours,  perhaps 
even  a  day,  death  ensues.  I  have  made  post-mortem  examination 
of  several  infants  who  have  died  under  such  circumstances,  chiefly 
in  the  ISTursery  and  Child's  Hospital,  about  six  from  recollection, 
and  have  found  considerable  uniformity  in  the  appearance  of  the 
viscera.  Only  a  small  portion  of  the  lungs,  sometimes  almost  none 
at  all,  was  found  inflated,  even  when  the  cries  had  for  a  time  been 
strong,  and  extravasated  blood  usually  in  considerable  quantity 
lay  upon  the  surface  of  the  brain,  evidently  having  escaped  from 
the  meningeal  vessels,  which  were  in  a  state  of  extreme  congestion 
in  consequence  of  the  protracted  or  difiicuit  birth.  Meningeal 
apoplexy  therefore  seems  to  me  the  chief  cause  of  the  ill-success 
attendino-  our  eflorts  to  save  those  Avho  are  so  far  resuscitated  as  to 
be  able  to  breathe. 


Caput  Succedaneum— Cephalaematoma. 

During  the  birth  of  the  child,  extravasation  of  blood  not  infre- 
quently occurs  in  the  part  of  the  scalp  which  presents.  This  results 
from  the  passive  congestion,  more  or  less  intense' according  to  the 
duration  of  labor  and  severity  of  the  labor-pains,  which  occurs  in 
the  presenting  part,  whether  scalp,  arm,  or  breech.  Caput  succe- 
DANEUM  is  the  term  employed  to  designate  the  swelling  thus  caused. 
Its  seat  is  the  loose  connective  tissue  of  the  scalp  external  to 
the  pericranium.  The  tumor  is  soft,  painless,  and  usually  located 
upon  the  occiput.  It  consists  partly  of  extravasated  blood,  but 
largely  of  serum  which  has  transuded  from  the  congested  vessels 
before  that  degree  of  congestion  was  reached  required  to  eflect  the 
transudation  of  the  corpuscles.  I  have  repeatedly  had  an  oppor- 
tunity to  examine  this  tumor  in  stillborn  infants  brought  from  the 
lying-in  wards  attached  to  the  K"ursery  and  Child's  Hospital,  and 
have  found  when  it  was  slight  that  it  consisted  almost  entirely 
of  serum,  but  ordinarily  when  dissected  it  presented  the  appear- 
ance of  a  bruise,  with  a  large  proportion  of  serum,  the  blood  and 
serum  infiltrating  the  scalp  to  a  greater  or  less  distance  beyond  the 
appreciable  limits  of  the  tumor.  Caput  succedaneum  requires  no 
treatment.     As  it  lies  in  the  loose  connective  tissue  of  the  scalp, 


CONJUNCTIVITIS    NEONATORUM.  65 

its  li(prKl  permeates  the  open  areolte  in  every  direction,  to  be 
rapidly  absorbed,  while  the  tumor  disappears.  The  subsidence  of 
the  swelling  is  usually  complete  within  forty-eight  hours. 

Occasionally  blood  is  extravasated  under  the  pericranium,  detach- 
ing it  from  the  bone.  This  occurs  in  connection  with  caput  succeda- 
neum,  and  is  observed  when  the  latter  declines.  The  tumor  thus 
produced  is  designated  cephalhematoma.  It  is  situated  upon  the 
occipital  or  parietal  bone,  near  the  posterior  fontanelle.  Its  base 
corresponding  with  the  denuded  bone  is  circular  or  oval,  and  it 
rarely  crosses  a  suture.  In  rare  instances  two  cephal^ematomata 
occur,  located  upon  the  occipital  and  one  parietal,  or  upon  both 
parietal  bones.  The  liquid,  being  surrounded  by  the  firmly  attached 
pericranium,  does  not  escape  in  the  surrounding  tissues,  as  the  caput 
succedaneum,  and  is  therefore  much  more  permanent.  It  flattens 
slowly  by  absorption,  and  does  not  disappear  till  after  several  weeks. 
At  the  age  of  six  months  a  slight  prominence  can  sometimes  be 
detected,  indicating  the  seat  of  the  tumor.  As  the  pericranium 
elevated  by  the  blood  does  not  lose  its  vitality,  it  soon  begins  to 
produce  bone,  so  that  after  some  days  a  ring  of  new  bone  can  be 
detected  by  the  finger  surrounding  the  base  of  the  tumor,  and  on 
the  inside  of  the  detached  membrane  a  layer  of  bone  is  produced, 
thin  at  first  and  flexible,  but  gradually  approximating  the  old  bone, 
and  becoming  firmer  as  absorption  occurs. 

Some  time  since,  a  specimen  was  presented  by  me  to  the  IST.  Y. 
Pathological  Society,  showing  this  accident  and  the  mode  of  cure. 
The  child  died  about  two  months  after  birth,  and  the  blood  consti- 
tuting the  tumor,  which  had  been  in  great  part  absorbed,  was  com- 
pletely encased  by  the  old  bone  below  and  the  new  thin  formation 
above.  The  cavity  at  length  becomes  obliterated,  and  there  only 
remains  some  thickening  of  that  part  of  the  cranium  which  corre- 
sponds with  the  location  of  the  tumor. 


CHAPTER   X. 

CONJUNCTIVITIS  NEONxVTORUM. 

Inflammation  of  the  conjunctiva  in  the  new-born  is  not  an  un- 
usual disease.  We  distinguish  two  forms  of  it,  diflering  in  gravity. 
It  commences  in  the  first  week,  and  commonly  about  the  third 
day. 


66  CONJUNCTIVITIS    NEONATOEUM. 

Causes. — The  causes  of  conjunctivitis  neonatorum  are  not  the 
same  in  all  cases.  The  grave  form,  which  has  been  designated 
purulent  ophthalmia,  has  been  known  to  occur  during  ei^idemics 
of  puerperal  fever,  probably  from  the  epidemic  influence.  Another 
cause,  one  which  is  easily  understood,  and  which  is  universally 
recognized  by  the  profession,  is  the  introduction  under  the  eyelids, 
during  the  birth  of  the  child,  of  a  particle  of  the  vaginal  secretion 
of  the  mother.  The  ordinary  leucorrhoeal,  and  still  more  gonor- 
rhoea!, secretion  has  this  efi:ect.  Moreover,  all  accoucheurs  meet 
occasional  sporadic  cases  in  cleanly  and  highly  respectable  families, 
occurring  from  some  unknown  cause,  though  perhaps  in  a  certain 
proportion  of  these  cases  also  a  little  of  the  leucorrhoeal  discharge 
coming  in  contact  with  the  conjunctiva  has  produced  the  inflam- 
mation. Certainly  in  private  practice  gonorrhoeal  infection  is  in 
only  a  small  proportion  of  cases  the  cause  of  purulent  ophthalmia 
of  the  new-born.  Some  observers,  as  Prof.  Gross,  believe  that  the 
most  frequent  cause  of  purulent  ophthalmia  of  the  new-born  is  at- 
mospheric. 

The  causes  of  the  mild  form  are  different  also  in  diflferent  cases. 
Prominent  among  them  are  bad  hygienic  conditions,  exposure  of 
the  eyes  to  a  current  of  cold  air,  and  the  introduction  of  a  little  of 
the  vernix  caseosa  or  soap  under  the  lids  in  the  first  washing. 

Symptoms.  Severe  Form. — In  the  beginning  the  palpebral  con- 
junctiva is  observed  to  be  red,  a  little  swollen,  and  its  cutaneous 
surface  presenting  a  faint  reddish  tinge.  The  light  appears  to  be 
painful,  and  the  child  is  fretful  and  sleeps  but  little;  but  the  eye 
itself  presents  its  normal  appearance.  The  progress  of  the  disease, 
however,  is  rapid,  and  in  twenty-four  or  thirty-six  hours  there  is 
so  much  tumefaction  that  the  upper  lid  extends  over  the  lower, 
and  it  may  be  impossible  to  separate  them  sufficiently  to  obtain  a 
view  of  the  eye.  The  tumefaction  is  due  to  oedematous  infiltra- 
tion. The  conjunctiva,  both  palpebral  and  ocular,  now  presents  a 
deep  red  hue,  is  thickened  and  swollen,  and  numerous  fine  granula- 
tions appear  upon  it:  occasionally  also  flakes  of  very  delicate  pseudo- 
membrane  can  be  observed  in  addition.  There  is  an  abundant  pro- 
duction of  pus  of  a  creamy  appearance,  sometimes  tinged  with  , 
blood,  which  oozes  out  when  the  lids  arc  separated.  A  critical 
period  has  now  arrived,  one  which  may  involve  the  destruction  of 
the  cornea  unless  the  case  is  promptly  and  judiciously  treated. 
Indeed,  the  gravity  of  the  disease  relates  chiefly  to  the  state  of  the 
cornea,  which  up  to  the  present  time,  notwithstanding  the  severity 
of  the  inflammation  and  the  amount  of  surrounding  infiltration,  has 


CONJUNCTIVITIS    NEONATORUM.  67 

remained  transparent  and  apparently  unaffected.  But  witliin  an- 
other twenty-four  hours  the  cornea  may  lose  its  polish,  and  grayish, 
opaque  spots  of  softening  appear  upon  it.  Soon  perforation  occurs, 
the  aqueous  humor  escapes,  and  the  iris  falls  forward,  closing  the 
aperture  and  preventing  further  loss  of  the  liquids  of  the  eye. 

I  have  observed  destruction  of  the  cornea  and  loss  of  sight  chiefly, 
first,  in  cases  of  true  gonorrhoeal  infection,  in  which  there  is  the 
maximum  amount  of  inflammation  and  tumefaction,  extending 
even  over  the  malar  bone  and  supra-orbital  ridge,  with  marked 
redness  and  elevation  of  temperature  of  the  lids ;  and,  secondly, 
with  a  less  degree  of  inflammation  in  those  who  were  highly  scro- 
fulous. In  other  cases  I  am  of  opinion  that  the  cornea  can  ordi- 
narily be  preserved  with  proper  treatment,  although  there  may  be 
so  much  purulent  discharge  and  oedema  that  it  may  be  impossible 
to  see  it  for  several  days.  Occasionally  the  cornea,  instead  of  slough- 
ing, becomes  infiltrated  to  a  greater  or  less  extent,  and  ulcerates, 
but  without  perforation.  As  the  patient  recovers,  cicatrization 
occurs. 

The  inflammation  soon  begins  to  decline.  The  swelling,  heat, 
and  redness  of  the  lids  and  conjunctiva,  and  the  granulations, 
gradually  disappear,  and  recovery  is  complete,  except  so  far  as  the 
cornea  may  have  been  injured. 

Mild  Form. — The  inflammation  is  from  the  first  of  a  mild  grade, 
pertaining  chiefly  to  the  palpebral  conjunctiva,  with  but  a  slight 
discharge  of  purulent  matter,  and  with  little  swelling  or  increase 
of  heat  in  the  lids.  Attention  is  directed  to  the  complaint  chiefly 
by  the  secretion  which  collects  in  the  angles  of  the  lids  or  upon 
their  border.  There  may  be  slight  intolerance  of  light,  and  ordi- 
narily minute  granulations  appear  upon  the  inflamed  mucous 
surface.  This  form  of  the  disease  may  disappear  within  a  few 
days,  or  it  may  be  protracted. 

The  conjunctivitis  of  the  new-born  is  contagious,  some  forms  of 
it  highly  so.  It  commences  on  one  side,  and,  without  precautions, 
commonly  within  a  few  days  extends  to  the  other. 

Treatment. — As  soon  as  the  inflammation  occurs,  the  opposite 
sound  eye  should  be  covered  with  a  compress,  kept  in  place  by 
strips  of  adhesive  plaster.  This  eye  should  be  examined,  however, 
once  or  twice  daily,  in  order  to  detect  the  commencement  of  in- 
flammation, and  the  bandage  reapplied. 

The  mild  form  of  conjunctivitis  requires  very  simj^le  treatment. 
Frequently  bathing  the  lids  with  lukewarm  water,  or  milk  and 
water,  so  as  to  remove  the  secretion  from  between  the  lids,  suflices 


68  CONJUNCTIVITIS    NEONATOEUM. 

ill  a  large  proportion  of  cases.  Among  the  poor  tlie  mothers  ordi- 
narily bathe  the  lids  with  breast  milk,  and  by  this  simple  treat- 
ment effect  a  cure.  If  the  inflammation  should  not  abate  soon  by 
this  treatment,  a  mild  collyrium  of  one-eighth  grain  of  nitrate  of 
silver  to  one  ounce  of  water  should  be  applied  between  the  lids  and 
allowed  to  run  under  them. 

The  severe  form,  or  purulent  ophthalmia,  on  the  other  hand,  re- 
quires prompt  and  judicious  management.  There  is  scarcely  a  dis- 
ease in  which  delay  is  more  disastrous. 

The  frequent  removing  of  the  pus  is  very  important,  which  is 
confined  in  large  quantity  underneath  the  closely  compressed  lids, 
and  by  its  pressure  and  irritation  increases  greatly  the  danger  of 
destruction  of  the  cornea.  Therefore  the  lids  during  the  height  of 
the  inflammation  should  be  pressed  apart  every  hour,  so  as  to 
allow  the  pus  to  escape,  and  the  space  between  the  lids  be  freed 
from  pus  by  a  camel-hair  pencil.  Occasionally  warm  water  may  be 
thrown  under  the  lids  by  a  small  glass  syringe,  to  wash  away  pus 
and  any  flakes  of  pseudo-membrane.  Probably  three  or  four  drops 
of  carbolic  acid  to  each  ounce  of  the  water  would  be  beneficial, 
from  the  known  good  effect  of  this  agent  on  suppurating  surfaces, 
but  I  have  never  employed  it. 

Medicinal  applications  to  the  inflamed  conjunctiva  should,  in 
my  opinion,  be  simple  and  mild,  but  frequently  applied.  It  is 
known  that  Von  Grafe  recommended  the  application  of  nitrate  of 
silver  as  a  caustic ;  but  the  operation  is  painful  and  difficult,  for  it 
requires  eversion  of  the  lids.  I  much  prefer,  in  the  treatment  of 
purulent  ophthalmia,  the  application  of  a  weak  solution  of  corro- 
sive sublimate  every  three  hours  between  and  under  the  lids,  the 
pus,  so  far  as  practicable,  having  been  first  removed  by  the  brush 
and  syringe.  I  employ  the  following  formula,  and  the  result  has, 
in  my  practice,  been  so  favorable  that  I  have  not  felt  justified  in 
trying  another: — 

I^.  Hyd.  chlor.  corros.  gr.  j  ; 
AqufE  rosarum  gij  ; 
Aqutc  ^vj.     Misce. 

Still,  the  beneficial  result  which  I  have  obseiwed  in  cases  treated 
with  this  collyrium  was  no  doubt  partly  due  to  the  frequent  re- 
moval of  the  pus,  the  importance  of  which  cannot,  in  my  opinion, 
be  too  highly  estimated.  In  ordinary  or  mild  cases  of  purulent 
ophthalmia,  a  light  poultice  of  ground  slippery  elm,  mixed  with 
sugar  of  lead  water,  will  be  found  useful ;  but  if  there  is  great  heat 
and  swelling  of  the  lids,  a  preferable  application,  while  the  inflam- 


DISEASES    OF    THE    UMBILICUS.  69 

mation  is  intense,  are  pieces  of  a  single  thickness  or  two  thick- 
nesses of  muslin  or  linen  an  inch  and  a  half  square,  taken  from  a 
cake  of  ice  on  which  they  lie,  and  renewed  every  two  or  three 
minutes  when  they  begin  to  be  warm.  When  the  inflammation 
has  become  less  intense,  and  the  danger  of  the  destruction  of  the 
cornea  is  passed,  the  poultice  or  sugar  of  lead  wash  may  be  em- 
ployed instead.  The  decline  of  the  inflammation  is  gradual,  though 
generally  pretty  rapid.  Occasionally  granulations  remain  upon  the 
lids.  If  they  do  not  diminish  and  disappear  when  the  purulent 
inflammation  has  ceased,  I  would  not  practise  excision,  as  recom- 
mended by  Vogel,  but,  having  everted  the  lids,  apply  a  solution  of 
nitrate  of  silver,  five  or  ten  grains  to  the  ounce,  to  the  granulations 
each  second  day,  and  immediately  wash  away  the  solution  by  a 
camel-hair  pencil  with  lukewarm  water,  and  apply  a  little  sweet 
oil  before  the  lid  is  returned.  If  the  granulations  do  not  disap- 
pear with  this  treatment,  they  may  be  lightly  touched  with  the 
smooth  surface  of  a  crystal  of  sulphate  of  copper,  followed  by  the 
application  of  water  and  sweet  oil.  By  this  mode  of  treatment, 
employed  from  the  commencement  of  the  inflammation,  a  large 
proportion  even  of  the  severest  cases  recover  with  good  vision. 


CHAPTER    XI. 

DISEASES  OF  THE  UMBILICUS. 

"When  properly  managed,  the  cord  desiccates  and  falls  off  between 
the  third  and  ninth  days.  The  nurse  should  not  be  allowed  to  oil  it, 
which  she  will  sometimes  do  unless  forbidden,  as  this  retards  desic- 
cation. If  the  dressing  of  the  cord  is  allowed  to  remain  Avet  from 
the  urine  or  otherwise,  the  cord  does  not  desiccate,  but  decom- 
poses. This  is  not  infrequent  in  poor,  intemperate,  and  slovenly 
families.  The  decaying  cord  is  apt  to  produce  inflammation  of  the 
navel.  Some  southern  physicians,  prior  to  the  late  war,  attributed 
the  prevalence  of  trismus  neonatorum  among  the  slaves  to  the  lesion 
of  the  navel  produced  by  this  cause,  the  trismus  being  then  essen- 
tially traumatic. 

Inflammation  of  the  Umbilical  Vein  and  Arteries. 

When  at  birth  the  cord  is  ligated,  if  the  child  is  in  its  normal 
state,  clots  form  in  the  umbilical  vessels  from  the  navel  inwards. 


70  DISEASES    OF    THE    UMBILICUS. 

Atrophy  of  the  vessels  follows,  and  by  the  twenty-fifth  clay  they 
are  represented  by  small,  firm,  fibrous  cords.  Sometimes,  though 
rarely,  a  true  phlebitis  or  arteritis  occurs  in  these  vessels  in  the 
first  days  after  birth,  due  either  to  the  low  vitality  of  the  child 
and  decomposition  of  the  fibrinous  plugs  and  gelatinous  substance 
of  the  cord,  or  the  entrance  into  the  vessels  of  purulent  or  decaying 
matter  from  the  fossa  of  the  umbilicus.  "We  are  sometimes  able, 
by  pressing  along  the  abdominal  walls  towards  the  umbilicus,  to 
squeeze  out  a  few  drops  of  the  decaying  and  purulent  substance. 
The  navel  itself  is  usuallv  inflamed  at  the  same  time.  This  is  a 
very  serious  disease.  Pus,  with  particles  of  disintegrated  fibrin,  is 
apt  to  pass  along  the  vessels  and  enter  the  circulation,  and,  being 
intercepted  in  distant  jiarts,  gives  rise  to  embolismal  inflammations. 
This  seemed  to  be  the  cause  of  several  subcutaneous  inflammations, 
and  points  of  embolismal  pneumonitis  in  a  new-born  infant  which 
I  attended  in  1868.  The  infant  belonged  to  a  family  highly 
scrofulous  and  prone  to  scrofulous  inflammations.  Umbilical 
phlebitis  and  arteritis  are  said  to  occur  most  frequently  in  Ij-ing-in 
institutions  during  epidemics  of  puerperal  fever. 

Treatment. — In  the  manner  already  indicated  we  should  attempt 
gently  to  press  out  any  purulent  and  decomposing  substance  from 
the  vessels,  and  the  infant  should  be  placed  with  its  abdomen  de- 
pendent so  far  as  it  can  be  done  without  rendering  it  uncomfort- 
able, so  as  to  aid  in  the  escape  of  the  liquids  b}^  gravity.  The  um- 
bilical fossa  should  be  kept  clean,  and  warm  water  containing  a 
little  carbolic  acid  may  be  dropped  upon  it  several  times  daily. 
The  abdomen  should  be  covered  with  a  soft  and  warm  poultice. 

Inflammation  and  Ulceration  of  Umbilicus. 

Inflammation  of  the  umbilicus  sometimes  occurs  in  the  new- 
born about  the  time  of  the  detachment  of  the  cord,  or  soon  after. 
It  probably  results  from  uncleanliness,  or  carelessness  in  the  man- 
agement of  the  cord,  by  which  irritating  and  decomposing  sub- 
stances remain  in  the  umbilical  fossa.  Sometimes  decomposing 
particles  from  the  cord  are  the  probable  irritant.  This  disease  is 
also  most  apt  to  occur  in  cachectic  infants,  or  those  of  scrofulous 
parentage,  whose  general  condition  renders  them  liable  to  inflam- 
mations. The  umbilicus  becomes  red,  slightly  swollen,  and  moist 
by  a  secretion.  Often  the  inflammation  remains  two  or  three  days 
in  this  mild  form,  receiving  no  treatment  except  from  the  nurse, 
and  disappearing  by  the  use  of  the  dusting  powder  which  she 


UMBILICAL    GRANULATIONS    OK    FUNGUS.  71* 

employs.  In  other  instances,  the  inflammation  extends  over  a 
radius  of  an  inch  or  even  more,  the  walls  of  the  umbilicus  become 
swollen  and  infiltrated,  and  ulceration  succeeds.  The  ulcer  is  cir- 
cular, occupying  the  site  of  the  navel,  and  attended  by  a  purulent 
discharge.  The  inliammation  may  now  gradually  abate,  and  the 
ulcer  heal  with  a  cicatrix  in  place  of  the  umbilicus.  But  in  other 
instances,  especially  if  there  is  a  decided  cachexia,  the  ulcer  ex- 
tends in  breadth  and  width,  till  finally,  in  the  worst  cases,  the 
peritoneum  becomes  involved,  and  perforation  or  peritonitis  occurs, 
with  death. 

Under  unfavorable  hygienic  circumstances,  the  blood  of  the 
infant  being  vitiated,  the  ulcer  may  become  gangrenous,  or  the 
inflammation  may  terminate  directly  in  mortification,  without  the 
formation  of  an  ulcer.  In  eitljer  case  the  prognosis  is  unfavorable, 
if  dark  brown  slough  occupies  the  site  of  the  umbilicus,  and  a 
sero-sanguineous  discharge  exudes  from  underneath.  The  common 
result  is  perforation,  peritonitis,  and  death  in  from  one  to  two 
weeks. 

Treatment. — Inflammation  of  the  umbilicus,  if  at  all  severe, 
and  especially  when  attended  by  any  destruction  of  the  tissues  in- 
volved, rapidly  reduces  the  strength.  In  such  cases  three  or  four 
drops  of  brandy  should  be  administered  every  two  hours  in  the 
breast  milk. 

In  the  simple  inflammation  the  navel  should  be  bathed  with 
lukewarm  water  three  or  four  times  daily,  and  the  ointment  of  the 
oxide  of  zinc  be  constantly  applied ;  or  if  there  is  little  or  no  dis- 
charge, the  navel  may  be  dusted  with  the  powdered  oxide  of  zinc. 
In  case  of  ulceration  the  navel  should  be  gently  washed  three  or 
four  times  daily  with  lukewarm  water,  to  which  carbolic  acid  is 
added — five  or  six  drops  to  the  ounce ;  and  if  there  is  much  inflam- 
mation, a  light  poultice  of  pulverized  slippery  elm  should  be  ap. 
plied  in  the  interval,  or  if  the  in^ammation  is  moderate,  the  balsam 
of  Peru.  If  gangrene  supervene,  the  parts  should  be  frequently 
bathed  with  the  carbolic  acid  water,  and  a  cloth  soaked  with  it  be 
applied  over  it.  The  slough  should  be  detached  as  soon  as  it  is  so 
far  separated  that  its  removal  causes  no  hemorrhage,  after  which 
the  treatment  for  ulceration  is  appropriate. 

Umbilical  Granulations  or  Fungus. 

"When  the  cord  falls,  granulations  sometimes  sprout  out  from  the 
exposed  raw  surface,  and  complete  cicatrization  is  impossible  till 


72  UMBILICAL    HEMOERHAGE. 

they  are  removed.  Tliey  form  a  rounded  mass  of  a  pale  reddish 
hue,  at  the  centre  of  the  umbilical  fossa,  bleeding  when  rubbed, 
and  causing  constant  moisture  of  the  umbilicus.  The  largest 
which  I  have  seen  had  perhaps  twice  the  size  of  a  large  pea,  and 
they  may  be  of  any  smaller  size. 

Treatment. — By  pressing  upon  the  umbilical  parietes  the  tumor 
rises  from  the  fossa,  so  that  a  silk  ligature  can  be  applied  around 
its  base,  when  the  mass  can  be  readily  removed  with  the  scissors. 
If  the  granulations  are  small,  they  may  be  removed  by  the  scissors, 
Avithout  the  ligature,  and  hemorrhage  prevented  by  touching  the 
surface  with  lunar  caustic. 


CHAPTER   XII. 

UMBILICAL  HEMORRHAGE. 

The  granulations  which  have  been  described  above  sometimes 
cause  considerable  hemorrhage  when  injured.  The  profuse  and 
even  fatal  hemorrhage  which  occurs  at  birth,  or  soon  after,  from 
too  loose  a  ligature  of  the  umbilical  cord,  or  from  laceration  or 
other  injury,  is  so  well  known,  and  its  cause  so  apparent,  that  it 
need  only  be  alluded  to  in  this  connection.  Bouchut  details  a  case 
in  which  death  occurred  even  before  birth,  from  this  form  of 
hemorrhage.  The  child  was  attached  to  the  j)lacenta  by  a  very 
short  cord,  which  prevented  delivery  till  it  parted  by  the  traction 
of  the  forceps ;  but  the  bleeding  from  the  umbilical  vessels  was  so 
profuse,  that  the  child  was  pallid  and  lifeless  when  born. 

There  is  another  form  of  umbilical  hemorrhage,  cases  of  which 
have  been  from  time  to  time  observed  for  more  than  a  century 
(one  of  the  first  on  record  was  reported  in  the  Gentleman'' s  Maga- 
zine, April,  1852,  by  Mr.  Watts,  a  physician  in  Kent,  England), 
but  little  was  done  to  elucidate  its  nature  till  three  American  phy- 
sicians made  it  the  subject  of  careful  study,  and  the  monographs 
which  they  have  published  upon  it  are  the  best  which  the  litera- 
ture of  the  profession  affords.  Dr.  Francis  Minot  read  his  paper, 
containing  the  statistics  of  46  cases,  before  the  Boston  Society  for 
Medical  Improvement,  in  April,  1852.  Prof.  Stephen  Smith  pre- 
pared his  paper,  containing  the  statistics  of  79  cases,  for  the  JN'ew 
York  Statistical  Society,  in  1855.  It  was  published  in  the  Neio 
York  Journal  of  3Iedicine  for  that  year.     Dr.  J.  Foster  Jenkins 


UMBILICAL    nEMOERIIAGE. 


73 


presented  his  monograpli  as  a  report  to  the  United  States  ISIedieal 
Association  in  1858,  and  it  was  published  in  the  Transactions  of 
the  Association  for  that  year.  This  paper  is  very  vahiable  on 
account  of  its  statistics,  as  the  writer  succeeded  in  collecting  the 
records  of  178  cases,  from  medical  journals,  and  gentlemen  of  the 
Association.  These  three  papers  contain  nearly  all  that  is  known 
in  reference  to  this  disease. 

Sex,  Age. — Females  are  less  liable  than  males  to  this  hemor- 
rhage. In  Jenkins's  cases,  31|  per  cent.  Avere  females,  65 1-  males. 
The  followino;  table  o-ives  the  ag-e  at  which  the  hemorrhage  com- 
menced  in  99  cases: — 


Ag 

a 

Nos 

Under  1 

dciy 

•                 •■•••• 

5 

"      2 

days 

•                 •                 •                 •                 •                 •                 • 

7 

"      3 

■                 •••••• 

6 

"      4 

•                 •••■(■ 

3 

5  to    7 

(inclusive)         .... 

33 

8  "10 

K 

25 

11  "15 

U 

16 

16  "21 

(( 

4 

56 

•                ...*•. 

1 

99 

Ordinarily  the  hemorrhage  commenced  very  soon  after  detach- 
ment of  the  cord,  but  in  not  a  few  the  cord  was  still  adherent. 

Causes. — The  common  proximate  cause  is  feeble  coagulability 
of  the  blood.  In  the  normal  state,  when  the  cord  is  ligated,  the 
fibrin  of  the  blood,  which  now  ceases  to  flow  in  the  umbilical  ves- 
sels, forms  coagula  so  firm  that,  by  the  time  the  cord  is  detached, 
hemorrhage  is  impossible.  But  in  the  majority  of  those  aftected 
with  this  disease  the  clots  are  so  soft  and  loose  that  they  do  not 
present  any  effectual  barrier  to  the  pressure  of  blood,  which  there- 
fore oozes  through  them  or  presses  them  away.  This  lack  of  co- 
agulability is  easily  demonstrated,  for  if  a  little  blood,  as  it  escapes, 
is  caught  in  a  vessel,  it  will  be  found  to  remain  liquid  a  long  time. 
This  dyscrasia,  or  morbid  s^te  of  the  blood,  which  we  therefore 
recognize  as  a  chief  cause  of  the  hemorrhage,  does  not  have  the 
same  origin  in  all  cases.  It  is  sometimes  due  to  inherited  syphilis. 
The  infant  aftected  with  it  may  be  plump,  and  appear  well  at  birth, 
but,  in  most  instances,  when  the  hemorrhage  is  to  occur,  it  is 
puny  and  cachectic,  exhibiting  also  local  manifestations  of  the  dis- 
ease with  which  it  is  aftected.  Thus,  in  a  case  in  my  practice,  the 
infant,  puny,  and  apparently  born  before  term,  was  observed  to 
have  several  blebs  of  pemphigus  on  the  first  day,  fi'om  some  of 


74  UMBILICAL    HEMORRHAGE. 

which  blood  soon  began  to  ooze,  but  the  fatal  umbilical  hemorrhage 
did  not  commence  till  after  two  weeks. 

In  about  one-fifth  of  the  cases  ecchymoses  or  petechite  have  been 
observed  upon  various  parts  of  the  surface,  aflbrding  additional 
proof  of  the  general  blood  disease. 

Jaundice  is  another  cause  of  impoverishment  of  the  blood  in  the 
new-born,  and  therefore  of  umbilical  hemorrhage.  The  writers 
who  have  collected  records  of  the  hemorrhage,  all  remark  the  fre- 
quent occurrence  of  the  icteric  hue,  both  before  and  during  the 
bleeding.  It  is  not  improbable  that,  in  certain  instances,  the 
jaundice  is  hematogenous,  arising  from  destruction  of  the  red  cor- 
puscles, and  liberation  of  the  h?ematin,  a  not  unusual  result  of 
a  profound  d^^scrasia,  whether  S3'philitic  or  originating  in  some 
other  cause.  But  in  other,  and  probably  most  instances,  the  jaun- 
dice i^roceeds  from  the  liver,  and  is  the  cause  of  the  change  in  the 
blood.  Thus,  in  five  of  Jenkins's  cases,  there  was  occlusion  of  the 
hepatic  or  common  bile-ducts,  and  jaundice,  from  the  presence  of 
biliary  acids  in  the  blood,  causes  diminution  in  the  amount  of  fibrin 
and  red  corpuscles.  In  the  ordinary  form  of  icterus  neonatorum,  the 
cause  of  which  is  found  in  the  relative  fulness  of  the  capillaries 
and  minute  bile-ducts  in  the  acini  of  the  liver,  the  coagulability  of 
the  blood  must  evidently  be  impaired  in  proportion  to  the  degree 
and  duration  of  the  jaundice. 

Poor  health  of  the  mother,  and  impoverishment  of  her  blood 
during  gestation,  whether  from  chronic  disease,  as  tuberculosis,  or 
anti-hygienic  conditions,  also  causes  impoverishment  and  dimin- 
ished coagulability  of  the  blood  of  the  child,  and  is  therefore  a 
cause  of  the  hemorrhao;e.  The  excessive  use  of  diluent  drinks  or 
alkalies  by  the  mother  is  believed  by  some  to  have  a  similar  efiect. 

In  certain  cases  the  hemorrhao;e  is  due  to  an  inherited  hemorrhao;ic 
diathesis.  In  nine  of  Jenkins's  cases  the  mothers  were  subject  to 
menorrhagia,  and  lial)le  to  bleed  freely  after  parturition,  and  from 
injuries;  and  seventeen  other  mothers  had  each  lost  more  than  one 
infant  from  umbilical  hemorrhage.  Probably  in  those  cases  in 
which  the  hemorrhage  commenced  bCTore  detachment  of  the  cord, 
and  external  to  the  point  of  insertion,  the  hemorrhagic  diathesis  is 
the  main  cause  of  the  flow. 

Although  the  cause  of  umbilical  hemorrhage  in  the  majority 
of  cases  is  the  vitiated  state  of  the  blood  itself,  high  authorities, 
among  others  Sir  James  Y.  Simpson,  have  met  cases  in  which 
the  hemorrhage  was  referable  to  the  state  of  the  vessels.     In  order 


UMBILICAL    HEMORRHAGE.  75 

that  the  vessels  Ue  eftcctually  closed  by  the  fibrinous  coagula,  their 
walls  should  have  their  normal  contractility,  but  this  is  in  great 
part  lost,  by  inflammation  (arteritis  or  phlebitis)  which  sometimes 
occurs  in  these  vessels,  as  we  have  already  seen.  Inflammation, 
whether  of  artery  or  vein,  causes  thickening  and  infiltration  of  its 
parietes,  loss  of  tone  on  the  part  of  the  fibres  of  which  they  are 
composed,  and  therefore  a  patulous  state  of  the  vessel.  Moreover, 
the  inflammation  is  apt  to  be  suppurative,  and  the  presence  of  pus 
in  the  vessel  obvitDusly  hinders  the  formation  of  a  firm  and  efiective 
coagulum. 

Symptoms. — Ordinarily  umbilical  hemorrhage  occurs  without  any 
premonition,  but  sometimes  it  is  preceded  by  jaundice.  Jenkins 
ascertained  that  jaundice  was  a  prodromic  symptom  in  41  out 
of  178  cases,  and,  with  the  icteric  hue,  constipation,  clay-colored 
stools,  deeply  tinged  urine,  etc.,  were  sometimes  recorded.  Rarely 
colicky  pains  and  vomiting  preceded  the  hemorrhage.  The  blood 
may  be  arterial  or  venous,  or  both.  It  oozes  slowly  or  rapidly, 
rarely  escaping  in  a  jet,  even  when  there  is  reason  to  believe  that  it 
is  arterial. 

Prognosis. — This  is  unfavorable.  Statistics  show  that  five  in 
every  six  perish.  The  prognosis  is  most  unfavorable  when  jaun- 
dice or  purpura  is  present.  Those  are  most  likely  to  recover  who 
have  a  healthy  parentage,  no  obvious  dyscrasia,  and  in  whom  the 
hemorrhage  occurs  late  and  is  not  profuse.  The  average  duration 
of  the  hemorrhage  in  82  fatal  cases  in  Jenkins's  collection  was  3| 
days,  the  minimum  being  only  three  hours.  After  the  arrest  of 
the  hemorrhage,  death  may  occur  from  exhaustion  or  the  dyscrasia. 

Treatment. — The  treatment  should  be  both  constitutional  and 
local.  It  is  important,  so  far  as  time  will  permit,  to  treat  the  dys- 
crasia, and  as  the  stools  are  apt  to  be  constipated,  a  laxative  is 
ordinarily  indicated.  A  laxative  is  not  only  useful  for  its  effect 
on  the  hepatic  circulation,  but  as  a  derivative.  Both  Smith  and 
Jenkins  recommend  calomel  for  this  purpose.  The  modes  of  treat- 
ing the  bleeding  part  have  been  various.  Those  most  deserving 
of  mention  are  the  following:  injecting  a  styptic  into  the  open 
vessels,  applying  a  styptic  by  compress  or  sponge  to  the  navel, 
covering  the  navel  with  dry  or  wet  plaster  of  Paris,  constant  pres- 
sure with  the  finger,  which  is  tedious,  but  which  maternal  solici- 
tude willingly  provides,  and  lastly  the  use  of  needles  with  ligature. 
All  of  these  methods  have  been  more  or  less  successful  in  arresting 
the  hemorrhage,  but  the  last  is  most   effectual,  though  painful. 


76  DIAGNOSIS    OF    INFANTILE    DISEASES. 

Two  needles  should  be  passed  through  the  umbilicus  at  right  angles, 
and  a  waxed  thread  wound  around  each  in  the  form  of  fio-ure  8. 
In  four  or  jS.ve  days  the  needles  should  be  removed,  and  a  poultice 
or  simple  dressing  applied. 


CHAPTER    XIII.       • 

DIAGNOSIS  OF  INFANTILE  DISEASES. 

General  Observations. 

Diseases  in  early  life  differ  in  important  particulars  from  those 
occurring  in  maturity.  Some  which  are  common  in  the  former 
age  are  unknown  or  are  rare  in  the  latter,  and  those  which  occur 
equally  at  all  ages  often  present  peculiar  symptoms  and  a  peculiar 
clinical  history  in  the  young.  Therefore  physicians  who  are  skil- 
ful in  treating  adults,  may  be  unskilful  in  treating  children.  Ex- 
cellence as  a  physician  of  children  can  only  be  achieved  by  special 
and  continued  study  of  their  ailments. 

Again,  as  regards  the  diseases  of  infancy,  in  which  period  there 
is  a  great  amount  of  sickness  and  a  large  mortality,  diagnosis  must 
evidently  be  made  from  the  objective  symptoms  ;  from  examining 
the  features,  attitude,  utterances,  the  pulse,  resi)iration,  etc.,  and 
inspecting  the  surfaces,  so  far  as  they  are  accessible  to  view,  and 
the  eliminative  products.  We  lack  for  this  age  the  important 
information  which  speech  affords.  Some  general  remarks,  there- 
fore, in  reference  to  the  appearances  and  functions  of  the  system  in 
early  life,  and  the  changes  which  they  undergo  in  various  patho- 
logical states,  seem  requisite,  in  order  to  a  clearer  appreciation  of 
the  symptoms,  and  more  ready  diagnosis  of  individual  diseases. 

Features,  External  Appearance  of  Head,  Trunk,  and  Limbs  in  Disease. 

In  the  new-born,  as  soon  as  respiration  and  the  new  circulation 
are  established,  the  cutaneous  capillaries  become  distended  with 
blood,  and  the  skin  presents  a  congested  appearance.  By  the  close 
of  the  first  week  this  external  hypersemia  begins  to  abate,  and  is 
soon  replaced  by  the  normal  capillary  circulation. 

Icterus  is  common  in  the  first  and  second  week.  Bouchut  attri- 
butes it  to  mild  hepatitis.     A  much  more  plausil^le  view  of  its 


FEATURES,  EXTERNAL  APPEARANCE  OF  HEAD,  ETC.   77 

causation,  and  probably  the  correct  one,  is  that  of  Frerichs,  who 
attributes  it  to  the  effect  on  the  hepatic  circulation  of  ligation  of 
the  umbilical  cord.  By  ligation  the  current  of  blood  through  the 
umbilical  vein  to  the  liver  ceases,  the  amount  of  blood  in  the 
hepatic  capillaries,  which  connect  with  the  branches  of  the  vein, 
diminishes,  and  then,  according  to  Frerichs,  diversion  occurs  of  a 
part  of  the  bile  from  the  hepatic  cells  into  the  capillaries,  while 
the  rest  flows  in  the  normal  manner  in  the  bile-ducts.  The  dc2i;ree 
of  jaundice  is  proportionate  to  the  amount  of  bile  which  enters 
the  circulation.  Icterus  neonatorum  is  not  a  disease  of  importance. 
It  subsides  without  medicine  in  the  course  of  one  or  two  weeks, 
when  the  circulation  through  the  liver  becomes  equalized  and 
regular. 

The  surface,  or  portions  of  the  surface,  of  the  new-born  often  pre- 
sent for  a  few  hours  a  livid  color  due  to  the  mode  of  delivery. 
Protracted  lividity  occurs  from  atelectasis  or  malformation  in  the 
heart  or  great  vessels ;  lividity  induced  by  exertion  or  excitement 
while  the  respiration  is  normal,  indicates  malformation  of  the  heart 
or  vessels ;  temporary  lividity  sometimes  occurs  in  severe  acute 
diseases,  especially  those  of  the  respiratory  organs ;  lividity,  whether 
temporary  or  permanent,  is  a  sign  of  imperfect  decarbonization  of 
the  blood. 

The  cheeks  of  children  are  congested  in  febrile  and  inflamma- 
tory diseases,  except  in  cachectic  or  prostrated  state  of  system. 
Transient  circumscribed  congestion  of  the  face,  ears,  or  forehead 
constitutes  a  reliable  sign  of  cerebral  disease.  Strabismus  occurring 
in  connection  with  febrile  reaction,  oscillation  of  iris,  inequality  of 
pupils,  and  drooping  of  upper  eyelids,  also  denote  cerebral  disease. 
The  pupils  are  contracted  during  sleep ;  evenly  dilated  in  death. 

Dilation  of  the  alse  nasi  during  inspiration,  with  contraction  of 
the  eyebrows  and  a  countenance  indicative  of  suflering,  attends 
severe  inflammation  of  the  respiratory  organs.  Absence  of  tears 
during  the  act  of  crying  shows  a  severe  and  probably  fatal  form  of 
disease  in  infants  over  the  age  of  four  months. 

Rapid  wasting  of  the  features,  causing  deep  suborbital  depres- 
sions, prominence  and  pointedness  of  the  cheek-bones  and  chin,  and 
hollowness  of  the  cheeks,  is  a  sign  of  a  severe  diarrhoeal  affection ; 
the  most  striking  examples  of  this  sudden  collapse  of  features  are 
afforded  by  patients  affected  with  cholera  infantum.  In  severe  cases 
of  this  disease,  the  physiognomy,  from  a  state  of  fulness  and  health, 
presents  in  a  few  hours  such  a  wasted  and  senile  appearance  that 
the  friends  with  difficulty  recognize  the  features  with  which  they 


78  DIAGNOSIS    OF    INFANTILE    DISEASES. 

are  familiar.  Muscular  tonicity  is  also  greatly  impaired  in  this 
disease,  that  of  the  orbicular  muscles  of  the  lips  and  eyelids  to 
such  an  extent  that  the  mouth  is  open  and  eyeballs  exposed  during 
sleep.  Great  emaciation  occurring  gradually,  is  a  symptom  of  sub- 
acute or  chronic  disease  of  a  grave  character,  often  of  tuberculosis 
or  chronic  entero-colitis. 

Strabismus  sometimes  occurs  in  children  who  have  no  serious 
disease.  It  is  then  due  to  simple  paralysis  of  one  or  more  of  the 
motor  muscles  of  the  eye.  But  when  supervening  upon  other 
symptoms  of  a  neuropathic  character,  it  is  a  grave  symptom,  indi- 
cating organic  disease  of  the  encephalon,  as  effusion,  meningitis,  etc. 
A  permanently  downward  direction  of  the  axes  of  the  eyes,  with 
smallness  of  the  face  and  great  expansion  of  the  cranium,  is  a  sign 
of  congenital  hydrocephalus.  The  scalp  in  this  disease  is  tense, 
bald,  or  sparingly  covered  with  hair,  the  fontanelles  and  sutures 
open  and  enlarged,  and  the  cranial  bones  yielding  to  pressure. 
Great  expansion  of  the  cranium  above  the  ears,  while  the  frontal 
portion  is  not  enlarged,  or  but  slightly,  denotes  hypertrophy  of  the 
brain. 

The  appearance  of  the  general  cutaneous  surface  possesses  much 
greater  diagnostic  value  in  the  diseases  of  infancy  and  childhood 
than  in  those  of  adult  life.  The  eruptive  fevers  so  common  in  the 
young,  and  comparatively  rare  in  the  adult,  reveal  themselves  to  us 
in  great  part  by  the  changes  which  they  cause  in  the  appearance  of 
the  integument.  The  peculiar  color  of  the  skin  in  constitutional 
syphilis,  hereafter  to  be  described,  and  which  is  more  marked  in 
infancy  and  early  childhood  than  at  any  other  age,  is  a  diagnostic 
sign  of  great  value  in  obscure  cases.  In  the  infant  the  cold  stage 
of  intermittent  fever  is  manifested,  not  by  muscular  tremors,  but 
by  lividity,  pallor,  and  the  goose-skin  appearance  of  the  surface. 

Bulbous  enlargement  of  the  fingers  and  incurvation  of  the  nails 
are  signs  of  cyanosis,  and  therefore  of  malformation  at  the  centre 
of  the  circulatory  apparatus,  or  of  tuberculosis,  or  chronic  pulmo- 
nary disease  attended  by  malnutrition.  Enlargement  of  the  spongy 
portions  of  bones,  causing  prominences,  softness,  and  bending  of  the 
bones,  and  consequent  deformity  of  the  limbs,  patency  of  the  fonta- 
nelles, a  large  and  square  shape  of  the  head  from  calcareous  deposit 
external  to  the  cranium,  arc  among  the  signs  of  rachitis. 

In  early  infancy  the  glands  of  the  skin  and  mucous  surfaces,  or 
which  connect  by  their  orifices  with  these  surfaces,  are  slightly 
developed.  Therefore  sensible  perspiration  and  lachrymation  are 
rare  under  the  age  of  three  months.    A  thick  ^Meibomian  secretion 


ATTITUDE  —  MOVEMENTS— THE    VOICE.  79 

of  a  piiriform  appearance  collecting  between  the  eyelids,  is  an  un- 
favorable prognostic  sign ;  it  indicates  a  state  of  great  depression ; 
it  is  observed  most  frequently  in  cerebral  and  intestinal  affections 
a  little  before  death.  Passive  congestion  of  the  vessels  of  the 
conjunctiva  sometimes  occurs  under  the  same  circumstances,  due 
to  feebleness  of  the  heart's  action,  and  imperfect  capillary  circula- 
tion.    It  indicates  the  near  approach  of  death. 

Attitude— Movements — The  Voice. 

A  sharp,  piercing  cry,  head  firmly  retracted,  flexure  of  the  limbs 
with  a  degree  of  rigidity,  adduction  of  the  great  toe,  clonic  or  tonic 
spasm  of  the  muscles,  irregular  movements  of  one  or  more  limbs, 
with  consciousness  impaired,  or  with  mental  hallucinations,  are 
symptoms  of  grave  disease  of  the  cerebro-spinal  system.  Irregular 
muscular  movements  partly  controlled  by  the  will,  and  occurring 
during  full  consciousness,  are  symptoms  of  chorea,  a  disease  nearly 
always  ending  favorably  in  children,  though  incurable  in  the  adult. 
Contraction  of  the  eyebrows,  turning  of  the  eyes  and  face  from 
light,  avoidance  of  noises,  as  if  painful,  are  signs  of  headache. 
Frequent  carrying  of  the  hand  to  the  ear,  and  pressing  with  the  ear 
against  the  breast  of  the  mother  or  nurse,  are  symptoms  of  otalgia. 
Frequent  carrying  of  the  fingers  to  the  mouth,  in  connection  with 
fretfulness  or  other  symptoms  of  suftering,  indicates  stomatitis, 
gengivitis  whether  from  difiicult  dentition  or  other  causes,  painful 
pharyngitis,  or  some  obstructive  disease  of  the  larynx.  Frequent 
rubbing  or  pressing  the  nose  may  be  due  to  intestinal  worms  or 
intestinal  irritation  from  other  causes.  It  may  be  due  to  coryza 
or  headache.  Frequent  forcible  rubbing  or  striking  the  nose  should 
lead  to  a  careful  examination  and  perhaps  guarded  prognosis.  It 
often  indicates  grave  cerebral  disease,  and  may  be  a  precursor  of 
convulsions. 

In  severe  obstructive  disease  of  the  larynx,  the  child  is  restless, 
moving  from  side  to  side.  In  most  inflammations  of  the  respira- 
tory organs,  a  semi-erect  position  gives  most  relief.  The  voice  in 
severe  laryngitis  is  often  hoarse  or  indistinct,  and  usually  so  in  the 
pseudo-membranous  form;  in  pleuritis  or  pneumonitis  it  is  re- 
strained and  abrupt,  since  the  movements  of  the  walls  of  the  chest 
give  pain. 

The  voice  in  severe  diseases  of  the  abdominal  organs  is  feeble 
and  plaintive.  It  is  sometimes  short  and  restrained  in  acute  dys- 
pepsia, in  peritonitis,  and  in  cases  of  great  abdominal  distension. 


80  DIAGNOSIS    OF    INFANTILE    DISEASES. 

The  horizontal  position  gives  most  relief  in  abdominal  diseases. 
In  case  of  abdominal  pain  the  patient  often  presses  his  hand  upon 
the  abdomen  and  flexes  his  thigh  over  it.  Perfect  quietude,  with 
features  sunken,  and  unchanged  by  smile  or  crying,  is  a  symptom 
of  severe  and  exhausting  diarrhoeal  affections. 

Respiratory  System. 

The  respiration  of  the  infant  under  the  age  of  six  months  is  very 
irregular,  and  it  is  more  irregular  the  nearer  the  time  to  birth.  If 
the  new-born  infant  is  closely  observed,  it  will  be  seen  to  sigh  often ; 
it  breathes  pretty  uniformly  and  regularly  for  a  moment,  and  then, 
without  appreciable  cause,  the  respiration  is  intermitted ;  it  holds 
its  breath  when  it  smiles  or  moves  its  head,  or  even  its  limbs;  it  is 
very  subject  to  hiccup;  this  is  more  common  the  first  week  of  life 
than  at  any  other  age.  So  much  is  the  breathing  of  the  young 
infant  disturbed  by  these  causes,  that  the  number  of  resj^irations 
ordinarily  varies  in  consecutive  minutes.  In  order,  therefore,  to 
determine  with  accuracy  the  frequency  of  the  normal  respiration 
for  this  time  of  life,  it  is  necessary  to  take  the  average  of  several 
observations. 

At  birth,  while  the  function  of  the  heart  has  for  months  been 
regularly  performed,  the  lungs  are  still  quiescent.  The  one  organ 
has  been  active  during  the  greater  part  of  foetal  development,  the 
other  is  yet  untried.  Hereafter,  the  new  order  of  things,  so  inti- 
mate is  the  relation  between  the  heart  and  lungs,  that  the  proper 
performance  of  the  function  of  one  is  essential  to  that  of  the  other. 
Therefore  the  commencement  of  respiration  and  the  return  of  cir- 
culation, which  is  modified  and  temporarily  arrested  at  birth,  are 
nearly  simultaneous.  Respiration  commences  in  the  first  half- 
minute  of  independent  existence ;  often,  indeed,  attempts  to  inspire 
occur  before  the  delivery  is  completed.  The  exceptions  to  this 
early  establishment  of  respiration  are,  after  tedious  or  unnatural 
births.     The  return  of  circulation  is  a  moment  later. 

Eespiration  IN  Health. — As  the  air-cells  at  birth  are  closed, 
the  establishment  of  respiration  is  difiicult.  The  air  at  first  pene- 
trates a  few  pulmonary  cells,  but  gradually  more  and  more  are 
inflated  through  the  forcible  inspirations  which  the  crying  of  the 
infant  produces,  till  after  a  variable  time  respiration  becomes  easy 
and  complete.  If  the  cry  is  feeble,  and  especially  if  with  this 
feebleness  there  is  considerable  congestion  of  the  brain,  the  result 


RESPIRATORY    SYSTEM. 


81 


of  tedious  birth,  the  full  establishment  of  respiration  is  in  a  cor- 
responding degree  gradual  and  slow. 

The  frequency  of  the  respiration  in  health  should  be  ascertained, 
in  order  to  determine  whether,  in  a  given  case,  it  is  abnormally 
accelerated.  The  following  table  embodies  the  result  of  observa- 
tions Avhich  I  have  made,  in  order  to  determine  the  normal  fre- 
quency of  respiration  in  the  first  year  of  life. 

Normal  Infantile  liesjnration  {number  ])er  minute). 


AGE. 

From  first 

From  close 

From  close  of 

Close  of 

Close  of 

half  hour  to 

of  first  week 

first  mouth 

third  to  clo.se 

sixth  month 

close  of  first 

to  close  of 

to  close  of 

of  sixth 

to  close  of 

First 
half 
hour. 

week. 

first  month. 

third. 

month. 

first  year. 

6 

< 

<v 

2, 

1ft 
< 

a5 

< 

o 

< 

a5 

< 

-Ji 

< 

< 

o 
as 
< 

Number  of  observations 

29 

28 

14 

13 

13 

16 

10 

25 

19 

6 

Extreme  number  of  respi- ) 
rations  per  minute \ 

25-104 

32-64 

40-64 

40-96 

28-60 

32-68 

28-52 

36-88 

24-40 

28-64 

24-36 

Mean   number  of  respira-  ) 
tions  per  minute ) 

48.5 

62 

52 

69 

45 

61 

39 

54 

33 

41 

29 

As  the  child  advances  from  the  age  of  one  year,  the  number  of 
respirations  per  minute  gradually  diminishes;  but  through  the 
whole  period  of  childhood  it  remains  greater  than  in  the  adult. 
At  the  age  of  five  years,  when  the  child  is  quiet,  but  awake,  it  is 
about  27 ;  at  the  age  of  ten  years,  about  22. 

Respiration  in  Disease. — In  cerebral  diseases  the  respiration  is 
apt  to  be  slow,  and  if  somnolence  occur,  intermittent,  and  accom- 
panied by  sighing.  In  young  infants,  in  the  drowsiness  which 
supervenes  when  the  blood  is  imperfectly  decarbonized,  during 
severe  attacks  of  capillary  bronchitis,  or  broncho-pneumonia,  respi- 
ration is  apt  to  be  intermittent. 

In  inflammatory  diseases  of  the  larynx  and  trachea,  respiration 
is  but  slightly  accelerated,  and,  if  there  is  no  obstruction,  its 
rhythm  is  normal;  if  there  is  obstructive  disease,  its  rhythm  is 
altered;  the  inspiratory  act  is  lengthened.  In  bronchitis,  resj)ira- 
tion  is  accelerated  in  proportion  to  the  degree  of  extension  down- 
ward of  the  inflammation.  It  is  in  no  disease  more  accelerated 
than  in  severe  capillary  bronchitis. 

In  pleuritis  and  pneumonitis,  the  respiration  is  accelerated  in 
proportion  to  the  extent  and  acuteness  of  the  inflammation.  In- 
spiration ending  abruptly,  and  succeeded  by  an  expiratory  moan, 
6 


82  DIAGNOSIS    OF    INFANTILE    DISEASES. 

is  a  symptom  of  both  pleuritis  and  pneumonitis  in  their  acute 
stages.  In  certain  cases  of  irritative  or  inflammatory  disease  of  the 
abdominal  organs,  respiration  presents  a  similar  character;  it  is 
modified  in  this  manner  in  consequence  of  the  pain  experienced  in 
movements  of  the  diaphragm.  Ordinarily,  however,  in  abdominal 
diseases,  respiration  is  nearly  natural. 

The  cough  is  an  important  diagnostic  symptom.  It  is  loud  and 
sonorous  in  spasmodic  croup ;  hoarse  or  harsh  in  true  croup ;  clear 
or  distinct  in  bronchitis ;  suppressed  and  painful  in  the  early  stages 
of  pneumonitis  and  pleuritis ;  convulsive,  and  with  more  inspira- 
tions than  expirations,  in  pertussis.  A  cough  is  one  of  the  first 
and  most  constant  symptoms  of  measles;  it  is  due  to  coexisting 
bronchitis.  Typhoid  and  remittent  fevers,  difiicult  dentition,  in- 
testinal worms,  irritating  ingesta,  and  severe  burns,  sometimes 
give  rise  to  a  cough,  which  is  nearly  dry  and  painless.  Occurring 
in  such  diseases,  it  is  sometimes  dependent  on  more  or  less  bron- 
chitis, to  which  the  primary  disease  has  given  rise. 

Circulatory  System. 

In  all  ages  and  countries  the  pulse  has  been  considered  an  im- 
portant symptom  both  in  diagnosis  and  prognosis.  It  aids  the 
practitioner  in  determining,  approximatively,  not  only  the  character, 
but  gravity  of  diseases.  It  is  somewhat  remarkable,  from  the  im- 
portance which  is  attached  to  the  pulse  in  medical  practice,  that 
its  natural  frequency  and  its  character  in  infancy  are  not  more 
accurately  known.  It  is  true  that  eminent  observers,  as  Trousseau 
and  Valleix,  have  published  statistics  relating  to  the  infantile  pulse 
in  health,  but  these  statistics  disagree,  and  therefore  do  not  afiford 
a  reliable  standard  with  which  to  compare  the  pulse  in  disease. 
Moreover,  some  published  statistics  of  the  pulse  possess  but  little 
value,  from  the  small  number  of  observations ;  some  from  the  fact 
that  records  of  the  infantile  pulse  are  grouped  with  those  of  older 
children ;  and  others  because  the  state  of  the  infant,  as  regards  its 
activity  or  emotions,  is  not  mentioned. 

Pulse  in  Health. — It  is  not  easy  to  collect  statistics  of  the 
healthy  pulse  for  the  period  of  infancy,  which  are  entirely  free  from 
erroi",  since  there  are  often  slight  derangements  of  the  system  in 
the  infant,  which  are  not  manifested  by  any  marked  symptoms, 
but  which  produce  acceleration  of  the  pulse.     In  collecting  the 


CIRCULATORY    SYSTEM. 


83 


following  statistics,  it  was  my  endeavor  to  avoid  sources  of  error 
so  far  as  possible. 

In  ordinary  cases  the  movements  of  the  heart  begin  about  one- 
eighth  of  a  minute  after  birth.  They  are  at  first  slow,  the  ven- 
tricular contractions  not  numbering  more  than  eight  or  ten  by  the 
close  of  the  first  quarter  minute.  In  the  second  quarter  the  cries 
are  vigorous,  and  the  pulse  now  is  rapidly  accelerated,  rising 
commonly  above  120,  and  sometimes  above  160  beats  per  minute. 
In  fifty-seven  observations  of  the  pulse  in  healthy  infants  during 
the  first  half  hour  of  life,  after  the  first  quarter  of  a  minute,  I 
found  that  the  extremes,  with  one  exception,  were  104  and  164 — 
average  139. 


Table  of  Infantile  Pulse  in  Health. 

AGE. 

First  week. 

From  close  of 

first  week  to 

close  of  first 

month. 

From  close  of 
first  month  to 
close  of  third. 

From  close  of 
third  month  to 
close  of  sixth. 

From  close  of 

sixth  month  to 

close  of  first 

year. 

Awake. 
Quiet; 

moving 
slightly; 
nursing. 

Asleep. 

Awake. 
Quiet; 
moving 
slightly; 
nursing. 

Asleep. 

Awake. 
Quiet; 
moving 
slightly; 
nursing. 

Asleep. 

Awake. 
Quiet; 

moving 
slightly; 
uur.sing. 

Asleep. 

Awake. 
Quiet ; 
moving 
slightly; 
nursing. 

Asleep. 

No.  of  obser-  ) 
vatioD... . .  I 

Extremes 

Mean 

22 
104-152 

126 

16 

108-140 

122 

10 

124-160 

1.39 

10 
104-144 

lis 

15 

112-148 

132 

17 
104-132 

lis 

25 

112-146 

129 

6 
104-116 
lOS 

20 

112-144 

127 

3 

109 

"  M.  Ledeberder,"  says  Bouchnt,  "  could  only  count  the  pulse  in 
the  first  minute  of  life  in  six  children,  and  he  has  observed  from 
72  to  94  pulsations."  Valleix  estimates  the  pulse,  between  the 
ages  of  two  and  twenty-one  days,  at  87.  Trousseau  states  that  the 
pulse,  in  the  first  week  of  life,  varies  from  78  to  150;  and  Dr. 
Gorham's  observations  are  somewhat  similar  to  Trousseau's.  My 
observations,  as  seen  from  the  above  table,  do  not  correspond  with 
the  assertions  of  Ledeberder  and  Valleix.  Indeed,  if  there  were 
no  conflicting  testimony,  there  would  still  be  a  strong  presum^^tion 
that  these  authors  are  in  error,  for  we  would  not  suppose  that  the 
pulse  of  the  infant,  in  whom  there  is  greater  functional  activity, 
both  muscular  and  visceral,  would  fall  so  much  below  that  of  the 
foetus.  It  is  probable,  from  the  expression  "  could  only  count  the 
pulse  ...  in  six  children,"  that  Ledeberder  and  j)erhaps  Val- 
leix counted  the  pulse  at  the  wrist,  which,  with  exceptional  cases, 
is  very  difficult  and  often  impossible  in  the  first  week  of  life,  and 


8i 


DIAGNOSIS    OF    IXFANTILE    DISEASES. 


that  they  missed  some  of  the  beats,  or,  not  unlikely,  sometimes 
counted  their  own  pulse.  Immediately  after  birth  there  is  so  little 
force  of  the  ventricular  systole,  and  the  extreme  arteries,  there- 
fore, of  the  system  pulsate  so  feebly,  that  neither  in  the  limbs  nor 
at  the  anterior  fontanelle  can  the  frequency  of  the  pulse  be  readily 
ascertained.  It  can  be  readily  and  accurately  ascertained  only  by 
auscultation,  or  by  placing  the  hand  on  the  precordial  region,  or 
directly  after  birth  by  the  pulsations  in  the  umbilical  cord. 

The  average  pulse  of  the  healthy  infant  in  the  first  and  second 
months  is,  according  to  Trousseau,  137  per  minute,  128  from  the 
third  to  the  sixth  month,  and  120  from  the  sixth  to  the  twelfth 
month.  It  is  seen  that  his  observations  agree  closely  with  mine, 
as  regards  infants  who  are  quiet  but  awake.  One  point  of  interest, 
established  by  the  above  statistics,  is  the  great  diminution  in  the 
frequency  of  the  pulse  in  sleep. 

Pulse  during  or  after  Active  3fovements  or  Great  Mental  Excitement. 


AGE. 


. 

Close  of  first 

Close  of  first 

Close  of  third 

Close  of  sixth 

First  -week. 

week  to  close  of  to  close  of  third 

to  close  of  sixth 

month  to  close 

first  moutli. 

month. 

month. 

of  first  year. 

140 

162 

176 

132 

132 

160 

156 

152 

148 

144 

140 

140 

158 

148 

152 

152 

152 

144 

144 

152 

152 

156 

198 

180 

156 

100 

Extremes 

140-160 

146-162 

144-180 

132-156 

132-198 

]\jean  

148 

152 

160 

147 

156 

It  is  seen,  by  the  above  table,  that  by  active  exercise  or  great 
mental  excitement  the  pulse  may  become  as  rapid  as  in  grave 
diseases.  There  is  greater  acceleration  of  pulse  from  the  emotions 
and  from  exercise  in  feeble  than  in  robust  children.  Obviously,  in 
order  to  determine  to  what  extent  the  pulse  is  accelerated  in  dis- 
ease, it  is  necessary  that  it  should  be  counted  during  a  state  of 
quietude.  As  the  age  increases,  it  is  less  and  less  influenced  by 
the  emotions  and  physical  exertion ;  still,  during  the  whole  period 
of  childhood,  such  influences  do  have  more  or  less  eflect  on  its 
frequency. 


Pulse  in  Disease. — Febrile  and  inflammatory  diseases  produce 
greater  acceleration  of  pulse  in  early  life  than  in  maturity.     Dis- 


ANIMAL    HEAT.  85 

eases,  or  (Icrangcments  of  system,  particularly  tliose  of  the  cTl2;es- 
tive  organs,  wliich  do  not  materially  affect  the  pulse  in  the  adult, 
often  cause  acceleration  of  it  in  children.  The  febrile  pulse  of 
early  life  usually  has  exacerbations  in  its  frequency.  These  com- 
monly occur  in  the  latter  part  of  the  day.  Distinct  and  more  or 
less  regular  febrile  exacerbations  and  remissions  are  common  in 
several  diseases  of  early  life,  some  of  which  are  serious,  while 
others  involve  little  danger.  Among  these  diseases  may  be  men- 
tioned difficult  dentition,  intestinal  worms,  incipient  meningitis, 
and  constipation.  An  intermittent  and  irregular  pulse  is  common 
in  fully  developed  meningitis  and  certain  other  severe  organic  dis- 
eases of  the  encephalon.  It  may  be  due  also  to  disease  of  the  heart, 
and  it  also  occurs  in  some  children  from  temporary  disturbance  of 
the  digestive  function.  The  pulse  is  slow  in  compression  of  the 
brain,  and  also  in  sclerema  of  the  new-born. 

Animal  Heat. 

The  internal  temperature  of  the  body  in  a  state  of  health  is 
uniform.  In  33  infants  under  the  age  of  seven  days,  M.  Roger 
found  the  average  temperature  98°. 6  Fahr.,  while  in  25  from  four 
months  to  fourteen  years  old  it  was  99°.  The  external  tempera- 
ture alone  varies  in  a  state  of  health,  according  to  the  temperature 
of  the  atmosphere. 

Elevation  of  temperature  above  the  normal  standard  is  a  sign 
of  inflammatory  and  febrile  affections.  The  increase  of  heat 
varies  according  to  the  character  of  the  disease  and  its  type.  In 
favorable  cases  of  inflammation  and  in  simple  fevers  it  is  not 
ordinarily  more  than  two  or  three  degrees.  The  greater  the  severity 
and  malignancy  of  inflammatory  and  febrile  diseases,' the  greater 
the  elevation.  An  elevation  of  more  than  six  degrees  indicates  a 
form  of  disease  which  is  likely  to  prove  fatal.  It  is  rare  that  the 
temperature,  even  in  fatal  cases,  rises  above  107°.  In  measles  the 
temperature  in  the  eruptive  stage  is  from  101°  to  103°  ;  in  scarla- 
tina from  102°  to  104°,  if  no  complication  exist. 

Reduction  of  the  internal  temperature  is  an  unfavorable  prog- 
nostic sign ;  it  is  observed,  a  few  hours  before  death,  in  infants 
who  are  greatly  reduced  by  certain  chronic  diseases,  as  entero- 
colitis. In  these  cases  the  tongue  and  even  sometimes  the  breath 
communicate  to  the  finger  or  hand  a  sensation  of  coldness. 

The  importance  of  thermometric  observations,  as  an  aid  to  the 
diagnosis  of  children's  diseases,  is  within  a  few  years  more  fully 


86  DIAGNOSIS    OF    INFANTILE    DISEASES. 

recognized  by  the  profession.  Two  diseases  whicli,  in  tlieir  com- 
mencement, present  very  similar  symptoms,  often  vary  as  regards 
the  temperature.  Thus,  meningitis  presenting  in  its  first  stages 
symptoms  very  similar  to  those  of  typhoid  fever,  has  a  lower  tem- 
perature till  an  advanced  period,  when  the  amount  of  heat  increases. 

Digestive  System. 

Inspection  of  the  buccal  and  faucial  surfaces  discloses  some  of 
the  most  frequent  local  diseases  of  infancy,  as  the  various  forms 
of  stomatitis,  and  others  which,  though  not  frequent,  involve  great 
danger,  as  gangrene  of  the  mouth,  diphtheria,  and  retro-pharyn- 
geal  abscess.  Inspection  of  the  tongue  aids  in  determining  in 
many  cases  whether  the  disease  is  pursuing  a  favorable  course,  or 
has  become  asthenic,  and  is  exhausting  the  vital  powers. 

Febrile  movements,  even  when  slight,  give  rise  to  coating  of  the 
tongue,  and  intumescence  and  distinctness  of  its  follicles.  The 
eruptive  fevers  are  attended  by  changes  upon  the  buccal  and 
faucial  surfaces  which  possess  diagnostic  and  prognostic  value. 
Hyper^emia  of  these  surfaces  appears  early  in  rubeola  and  scarlatina, 
prior  to  those  phenomena  which  are  justly  regarded  as  pathogno- 
monic. It  is  therefore  often  an  important  sign  in  the  initial  period 
of  those  diseases  when  the  diagnosis  is  obscure.  The  appearance  of 
the  fauces  in  diphtheria  and  croup,  indicating  not  only  the  nature 
of  the  disease,  but  its  gravity,  need  only  be  referred  to  in  this  con- 
nection. 

Inspection  of  the  buccal  and  faucial  surfaces  sometimes  enables 
us  to  form  a  probable  opinion  in  reference  to  the  nature  of  diseases 
which  are  seated  in  other  parts.  In  the  infant  protracted  stomatitis 
is  a  common  accompaniment  of  chronic  diarrhoea,  and  it  indicates 
its  inflammatory  nature. 

Vomiting  is  more  frequent  in  infancy  than  in  childhood,  and  in 
either  period  than  in  adult  life.  It  is  common  in  cerebral  aifec- 
tions,  and  is  one  of  the  first  symptoms  of  scarlet  fever,  and  it  is 
not  uncommon,  though  less  frequent,  in  the  commencement  of  the 
other  essential  fevers  and  of  acute  inflammations.  It  is  a  symp- 
tom of  indigestion,  entero-colitis,  cholera  infantum,  and  intussus- 
ception ;  it  is  common,  also,  after  the  paroxysmal  cough  of  pertussis, 
and  not  infrequent  in  the  bronchial  inflammations  of  young  infants ; 
in  both  which  diseases  it  is  excited  by  the  muco-puruleut  matter 
upon  the  faucial  surface. 

Intestinal  gas  is  in  part  secreted  or  exhaled  from  the  mucous 


DIGESTIVE    SYSTEM. 


87 


membrane,  as  the  experiments  of  Hunter  and  others  have  shown, 
and  it  is  in  part  the  product  of  chemical  changes  in  the  food.  A 
certain  amount  of  gas  in  the  intestines  is  normal ;  it  subserves  a 
useful  purpose.  An  abnormal  amount  of  it  is  common  in  various 
diseases,  as  indigestion,  chronic  entero-colitis,  peritonitis,  typhoid 
fever.  It  is  a  frequent  cause  of  gastralgia  and  enteralgia  in  the 
infant.  In  scrofulous  or  feeble  infants,  with  impaired  muscular 
tonicity  and  faulty  digestion,  the  abdomen  is  often  habitually 
more  or  less  distended  with  gas,  which  does  not,  under  such  circum- 
stances, give  rise  to  pain  or  other  local  symptoms ;  it  has  signifi- 
cance as  showing  the  general  condition  of  the  child. 

In  the  rachitic,  whose  thorax  is  compressed  and  liver  often  en- 
larged, while  the  vertebral  column  is  shortened,  the  abdomen  is 
commonly  protuberant.  In  feeble  chil- 
dren, not  decidedly  rachitic,  whose  lungs 
are  seldom  fully  inflated,  and  whose  chests 
are  consequently  depressed,  the  abdomen 
is  also  prominent.  The  accompanying 
wood-cut  represents  one  of  these  cases, 
presented  for  treatment  at  the  out-door 
department  at  Bellevue. 

In  feeble  children  who  have  suffered 
from  repeated  and  protracted  attacks  of 
bronchitis,  and  whose  chest-walls  are  con- 
sequently depressed,  a  similar  abdominal 
prominence  occurs. 

Retraction  of  the  abdominal  walls  is 
common  in  meningitis,  and  in  many  ex- 
hausting diseases.  Tenesmus  is  a  symp- 
tom of  intussusception  in  the  infant,  and 
of  colitis  in  children. 

Much  light  is  thrown  on  the  character  of  intestinal  diseases  by 
the  appearance  of  the  stools.  Muco-sanguineous  stools,  accompanied 
by  fever,  are  a  sign  of  colitis.  Stools  containing  unmixed  blood, 
and  not  accompanied  by  fever,  may  result  from  a  rectal  polypus 
and  from  purpura  hemorrhagica.  Scanty  evacuations  of  blood 
with  obstinate  constipation,  are  a  symptom  of  intussusception  in 
infants. 

The  alvine  discharges  of  infants  often  present  a  green  color; 
sometimes  they  have  the  normal  yellow  hue  when  passed  from  the 
bowels,  but  become  green  on  exposure  to  tlie  air,  or  from  reaction 
of  the  urine.     By  the  microscope   the  green  coloring   matter  is 


88  DIAGNOSIS    OF    INFANTILE    DISEASES. 

seen  to  occur  in  small  irregular  masses.  This  green  substance  has 
been  supposed  to  be  bile.  I  have  satisfied  myself  that,  as  met  in 
the  stools  of  the  infant,  it  is  commonly  produced  by  the  action  of 
the  intestinal  secretions  on  the  contents  of  the  intestines ;  perhaps 
the  action  is  upon  the  bile  which  is  mingled  with  the  contents. 
I  have  often  noticed  the  contents  in  and  above  the  jejunum  yellow, 
while  in  and  below  the  ileum  the  color  was  green. 

The  green  hue  may  occur  from  very  different  causes.  It  may 
be  due  to  overfeeding,  to  the  action  of  cold,  to  irritating  ingesta, 
to  inflammation,  etc. ;  it  may  be  transient,  subsiding  within  a  day 
or  two,  or  it  may  continue  several  days.  All  infants,  at  times, 
have  green  evacuations,  even  when  they  appear  in  good  health. 

The  alvine  discharges  of  infants,  in  a  large  proportion  of  cases 
of  cliarrhoeal  affections,  give  an  acid  reaction  with  litmus  paper. 
This  acid,  if  in  considerable  quantity,  is  irritating,  increasing  the 
peristaltic  movements  of  the  intestines,  and  the  functional  activity 
of  the  intestinal  follicles,  causing  erythema  of  the  skin  around 
the  anus,  and  reacting  upon  and  intensifying  the  intestinal  dis- 
ease. Hence  the  indication  for  the  use  of  antacids  in  the  diar- 
rhoeal  affections  of  infancy. 

The  presence  of  intestinal  worms,  and  the  species,  may  be  ascer- 
tained by  microscopic  examination  of  the  stools  of  the  child  who 
is  affected  with  these  entozoa.  The  stools  contain  ova,  which  dif- 
fer in  size  and  shape  according  to  the  species  of  worm. 

Nervous  System. 

Pain. — This  symptom  affords  important  aid  to  the  physician  in 
determining  the  seat  and  nature  of  the  diseases  of  children.  Pain 
in  the  head  may  occur  in  them  from  coryza  involving  the  frontal 
sinuses,  febrile  movement  in  the  commencement  of  an  essential 
fever,  or  of  inflammation  of  one  of  the  organs  of  the  trunk. 
Produced  by  such  a  cause,  it  abates  in  two  or  three  days.  If  it  is 
protracted,  whether  constant  or  intermittent,  it  is  almost  never 
neuralgic,  as  it  so  often  is  in  the  adult,  but  it  is  due  to  organic 
disease  of  the  brain  or  meninges.  Complaint,  therefore,  of  head- 
ache in  a  child,  without  any  apparent  general  cause,  or  local  cause 
external  to  the  cranium,  should  awaken  solicitude,  and,  if  the 
headache  is  protracted,  the  prognosis  should  be  doubtful,  even  if 
other  symptoms  are  absent. 

Grave  thoracic  or  abdominal  inflammations  in  the  adult  are 
almost  always  attended  by  a  corresponding  amount  of  pain  and 


NERVOUS    SYSTEM.      .  89 

tenderness  ;  bnt  in  children  these  symptoms  are  often  ahsent,  or, 
when  present,  are  often  not  commensurate  with  the  amount  of  dis- 
ease. Thus,  entero-colitis  of  nursing  infants  is,  in  a  large  propor- 
tion of  instances,  almost  free  from  these  symptoms,  and  the  same 
may  be  said  of  many  cases  of  the  form  of  pneumonia,  which  is 
common  in  young  chik^ren,  namely,  that  produced  by  extension  of 
inflammation  from  the  bronchial  tubes  and  that  from  hypostasis. 

Pain  in  the  chest  or  abdomen,  occasional  or  constant,  continuing 
for  weeks  or  months,  unattended  by  symptoms  of  thoracic  or  abdo- 
minal disease,  indicates  caries  of  the  vertebras.  Its  most  common 
seat  is  the  epigastric,  umbilical,  or  hypochondriac  region.  It  is  a 
neuralgia  due  to  irritation  of  the  sensitive  root  of  one  or  more  of 
the  spinal  nerves.  It  is  a  very  important  symptom  to  the  diagnos- 
tician, showing  the  nature  of  the  disease,  which  in  its  incipiency 
is  so  obscure.  Pain  in  the  leg,  especially  the  inside  of  the  knee, 
is  of  a  similar  character,  indicating  disease  of  the  hip-joint. 

Children  with  certain  acute  febrile  and  inflammatory  diseases 
sometimes  have  hyper?esthesia  of  portions  of  the  surface,  especially 
marked  upon  the  anterior  aspect  of  the  trunk.  The  phj'sician  might 
be  misled  into  the  belief  that  the  tenderness  indicated  the  seat 
of  the  disease ;  but  the  pain  of  hypereesthesia  can  be  determined 
by  the  fact  that  it  is  so  extensive,  is  less  on  firm  than  light  pres- 
sure, and  is  especially  observed  upon  the  inner  surface  of  the  thighs. 
The  syniptoms  pertaining  to  the  nervous  system  present  in  the 
various  diseases  treated  of  in  this  book  will  be  fully  described  in 
connection  with  those  diseases,  and,  therefore,  need  not  detain  us 
in  this  connection. 


PART  II. 


CONSTITUTIONAL  DISEASES. 


SECTIO]^  I. 


DIATHETIC  DISEASES. 


CHAPTER    I. 


RACHITIS. 


Rachitis,  or  rickets,  is  a  disease  of  the  general  nutritive  process  ; 
but  the  structural  changes  which  attend  and  characterize  it  are 
most  conspicuous  in  the  bones. 

Age. — Rachitis  commences  in  most  instances  between  the  ao;es 
of  six  months  and  two  years.  Now  and  then  we  meet  cases  of  its 
earlier  as  well  as  later  commencement,  and  skeletons  are  preserved 
in  museums,  which,  it  is  claimed,  establish  the  fact  that  in  rare 
instances  rachitis  is  congenital.  Yirchow  alludes 
to  such  a  specimen  in  the  Wurzburg  Museum,  and 
Ritter  von  Rittershain  describes  another  in  the 
Museum  of  the  Franz  Joseph  Hospital  in  Prague. 
In  the  Wood  Museum  of  Bellevue  Hospital  is  a 
similar  skeleton  presented  by  myself.  The  infant 
in  this  case  died  a  few  hours  after  birth,  of  atelec- 
tasis, apparently  produced  by  the  contracted  state 
of  the  thoracic  walls.  This  skeleton  exhibits  most 
of  the  curvatures  and  deformities  which  occur  in 
rachitis,  but  as  the  nodosities  of  the  articulations 
are  wanting,  and  the  bones,  apart  from  their  gene- 
ral shape,  appear  normal,  competent  pathologists 
of  this  city  have  expressed  the  opinion  that  the 
malformation  in  this  case  was  probably  the  result 
of  some  unknown  error  of  nutrition  rather  than 
rachitis.  The  annexed  representation  will  allow 
the  reader  to  judge  for  himself.     The  parents  are 


92  RACHITIS. 

hard-working  Englisli  people,  having  children  who  appear  scro- 
fulous, hut  not  rachitic. 

Enlargement  of  the  costo-chondral  articulations,  known  as  the 
"  rachitic  rosary,"  which  is  one  of  the  earliest  and  most  reliable 
signs  of  rachitis,  has  been  observed,  though  rarely,  in  infants  of 
two  or  three  months.  It  should  not,  however,  be  regarded  as  a 
sio-n  of  rachitis  unless  the  enlaro-ement  is  so  ffreat  that  it  can  be 
readily  appreciated  by  examination  through  the  integument  or  by 
sight,  for  in  young  children,  with  the  bones  in  the  process  of 
normal  development,  these  points  always  have  a  greater  diameter 
than  that  of  the  ribs.  After  the  age  of  two  years  the  number  of 
those  affected  with  rachitis  gradually  becomes  less  as  we  pass  to- 
wards manhood. 

Published  statistics  relating  to  the  commencement  of  rachitis 
have  been  derived  chiefly  from  European  hospitals.  Of  521  cases 
observed  by  Ritter  von  Rittershain,  266  were  under  the  age  of 
twelve  months,  and  91  under  six  months.  Of  Hillier's  cases,  7 
were  six  months  old  or  under,  27  from  six  to  twelve  months,  40 
from  twelve  to  twenty-four  months,  40  from  two  years  to  four 
years,  and  3  over  the  age  of  four  years.  As  rachitis  so  often  com- 
mences insidiously,  these  statistics  must  be  considered  only  ap- 
proximately correct,  especially  as  regards  those  cases  which  are 
supposed  to  have  had  an  unusually  late  commencement. 

Is  rachitis  ever  developed  in  the  adult?  Osteo-malacia,  or 
mollities  ossium,  a  rare  disease  of  adults,  occurring  with  few  ex- 
ceptions in  women  after  childbirth,  resembles  rachitis,  since  it  is 
attended  with  softening  of  the  bones  from  the  absorption  of  their 
calcareous  element.  Trousseau,  and  following  him,  Bouchut,  believe 
in  their  essential  identity,  regarding  their  differences  as  due  to  the 
difference  in  age,  and  especially  to  the  fact  that  in  osteo-malacia 
the  bone  has  attained  its  growth,  whereas  in  rachitis  it  is  still 
growing.  Moreover,  as  arguments  in  favor  of  their  close  relation- 
ship, rachitis  and  osteo-malacia  are  found  to  require  very  similar 
treatment,  and  women  after  childbirth  resemble  children  as  regards 
aptitude  for  disease.  That  the  two  pathological  processes  are  not, 
however,  exactly  identical,  appears  from  the  researches  of  Virchow. 
In  osteo-malacia  the  bones  become  soft  and  flexible  from  absorption 
of  the  lime  salts,  whereas  in  rachitis  there  does  not  appear  to  be 
any  more  loss  of  the  lime  than  occurs  in  the  normal  growth  of 
bone,  but  its  further  deposit  is  arrested.  In  the  normal  develop- 
ment of  bone  the  deposit  of  lime  is  in  excess  of  the  absorption, 
but  in  rachitis,  the  absorption  continuing,  with  an  arrest  of  depo- 


RACHITIS.  93 

sition,  it  is  easy  to  see  how  the  bone  soon  becomes  soft  and  yielding, 
as  in  osteo-malacia,  with  enlargement  of  its  canals  and  cancelli. 

Causes. — Ivachitis,  as  we  have  stated  elsewhere,  is  entirely  dis- 
tinct in  its  nature  from  scrofula.  The  scrofulous  are  not  likely  to 
become  rachitic,  nor  the  rachitic  scrofulous.  Proneness  to  low 
grades  of  inflammation  or  to  hyperplasia  of  the  lymphatic  glands, 
which  characterizes  scrofula,  seldom  exists  in  connection  with  swell- 
ing of  the  bones  or  other  manifestations  of  rachitis.  The  diti:er- 
euces  between  the  scrofulous  and  rachitic  diatheses,  which  indeed 
seem  to  exclude  each  other,  are  marked.  The  scrofulous  are  well' 
developed  and  of  good  height,  as  a  rule,  while  the  rachitic  are 
stunted.  Scrofula  manifests  itself  not  less  frequently  in  childhood 
than  in  infancy,  whereas  rachitis  we  have  seen  is  especially  a  dis- 
ease of  infancy.  Again,  as  showing  the  difterence  between  the 
two,  scrofula  is  not  infrequently  associated  with  tuberculosis, 
whereas  rachitis  with  tuberculosis  is  rare. 

Residence  in  a  cold  and  moist  climate,  or  in  dark,  damp,  and  ill- 
ventilated  apartments,  is  a  cause  of  rachitis.  Therefore  it  is  more 
common  in  the  north  of  Europe  than  in  the  warm  and  equable 
climate  of  southern  Europe ;  in  the  damp  and  dark  basements  and 
alleys  of  the  citj^,  than  in  dry  and  airy  country  residences.  In 
deep  valleys,  shut  out  from  the  solar  rays,  rachitis  is  more  common 
than  among  people  of  the  same  habits  and  social  position  living  in 
elevated  and  sunlit  localities. 

A  common  cause  of  rachitis  is  the  use  of  insufficient  or  improper 
food.  This  has  been  ascertained  not  only  from  the  history  of  rachitic 
children,  but  from  experiments  on  animals.  Diminution  in  the 
relative  amount  of  lime  and  consequent  softening  of  the  bones 
have  been  produced  in  various  animals  by  the  use  of  scanty  food, 
or  food  deficient  in  nutritive  propei'ties.  Artificial  feeding  of  young 
animals  at  the  time  when  nature  designed  that  they  should  be 
nourished  by  the  mother's  milk  has  had  the  same  result.  (Experi- 
ments by  M.  Jules  Guerin  and  others.)  Rachitis  is  more  apt  to 
occur  in  those  who  are  prematurely  weaned  than  in  those  who  nurse 
the  full  time.  Those  are  most  likely  to  become  rachitic  in  a  marked 
degree,  even  fatally,  who  at  the  same  time  have  scanty  and  impro- 
per food,  and  reside,  in  damp,  dark,  and  insalubrious  localities. 

An  hereditary  predisposition  to  rachitis  must  also  be  admitted, 
since  infants  born  of  rachitic  parents  are  more  likely  to  become 
rachitic  than  are  those  of  healthy  parentage.  The  mothers  pre- 
sented traces  of  rachitis  in  27  out  of  71  cases  observed  by  Ritter 
von   Rittershain.     A   mother  in   habitual   ill-health   and  poorly 


94  RACHITIS. 

nourished,  though  without  actual  disease  during  the  period  of 
gestation,  is  more  apt  to  have  rachitic  offspring  than  is  a  mother 
whose  health  is  habitually  good. 

It  is  not  true,  as  some  have  stated,  that  all  that  is  required  to 
produce  rachitis  is  a  certain  lowering  of  the  vital  powers,  since  all 
greatly  enfeebled  infants  would  become  rachitic,  whereas  only  a 
portion  of  such  present  the  anatomical  changes  which  characterize 
this  affection.  Cachexia  is,  however,  the  important  element  in  its 
causation,  and  therefore  the  rachitic  state  not  infrequently  super- 
venes on  certain  exhausting  diseases,  as  the  eruptive  fevers,  per- 
tussis, and  entero-colitis. 

Anatomical  Characters.  1st  Stage. — M.  Lebert  says:  "In 
rachitis  the  bone  is  diseased  in  all  its  histological  elements,  and  the 
skeleton  in  its  totality."  It  commences  with  proliferation  of  the 
periosteum  and  of  the  cartilages  of  the  epiphyses.  In  the  norznal 
state  the  new  tissue  formed  by  this  proliferation  changes  into  bone 
by  the  deposit  of  the  lime  salts,  that  formed  from  the  periosteum 
increasing  the  thickness  of  the  bone  ;  that  from  the  cartilages,  their 
length ;  but  in  rachitis,  as  already  stated,  the  osseous  change  does 
not  occur.  Soon  the  areolae,  which  abound  in  the  ends  of  the  long 
bones,  in  the  short  bones,  and  in  the  diploe  of  the  flat  bones,  are 
observed  to  enlarge,  and  the  laminae  of  which  the  compact  bone  is 
composed,  to  separate  more  or  less  from  each  other,  forming  inter- 
lamellar  spaces. 

The  areolar  and  interlamellar  spaces  are  filled  with  a  gelatini- 
form  fluid  of  a  pale  reddish  color.  The  same  substance  fills  the 
medullary  canals,  and,  in  -certain  situations,  more  or  less  of  it  is 
deposited  between  the  periosteum  and  the  external  surface  of  the 
bone.  The  amount  of  subperiosteal  deposit  in  a  given  place,  de- 
pends in  a  measure  on  the  tensity  and  degree  of  adherence  of  the 
periosteum.  Thus  when  curvatures  occur,  the  quantity  of  this 
substance  deposited  over  the  concave  surface  of  the  bone,  where 
the  periosteum  is  lax,  is  considerable,  while  over  the  convex  sur- 
face, where  it  is  tightly  drawn,  it  is  absent  or  scanty.  This  sub- 
stance adheres  quite  firmly  to  the  surface  of  bone,  with  which  it 
is  in  contact,  though  at  autopsies  more  or  less  of  it  can  be  washed 
away  by  a  stream  of  water. 

The  periosteum  and  medullary  membrane  are  more  vascular  than 
in  their  normal  state,  presenting  a  deep  red  color,  and  the  vascu- 
larity of  the  bone  itself  is  increased. 

2d  Stage. — The  second  stage  is  that  of  curvatures  and  deformity. 
The  laminae  of  compact  portions,  and  the  walls  of  the  a'reolse,  in 


EACIIITIS.  95 

parts  that  arc  cancellous,  become  gradually  tliinner  and  more 
yielding.  Here  and  there  loss  of  the  animal  matter  in  connection 
with  the  mineral,  occurs,  producing  new  apertures  and  channels, 
in  some  of  which  bloodvessels  of  a  new  growth  are  developed. 
Occasionally  portions  of  bone  become  detached,  and  lie  as  sequestra 
in  the  midst  of  the  gelatiniform  substance.  The  shape  of  the  me- 
dullary cavity  changes.  The  extremities  of  the  cavity  are  con- 
siderably larger  than  its  central  portion.  In  this  second  stage,  in 
typical  cases,  the  relative  proportion  of  calcareous  matter  being 
greatly  reduced,  and  the  new  gelatiniform  substance  still  semi- 
liquid,  if  an  opportunity  occur  of  examining  the  skeleton,  the  long 
bones  can  be  bent,  and  their  epiphyses,  as  well  as  the  flat  and  short 
bones,  compressed,  and,  in  some  instances,  even  crushed  between 
the  thumb  and  fingers.  "The  bones  in  this  state  can  be  cut  with  a 
knife  with  as  much  ease,"  says  Trousseau,  "  as  a  carrot  or  other 
soft  root.  In  cases  in  which  the  absorption  has  been  considera- 
ble, if  the  bone  removed  from  the  cadaver  is  dried,  it  will  be  found 
possible  to  respire  through  it,  so  great  is  its  porosity,  and  its  weight 
is  from  six  to  eight  times  less  than  that  of  normal  bone. 

If  rachitis  commence  at  an  age,  as  it  commonly  does,  when  the 
diaphyses  and  epiphyses  of  the  long  bones  are  united  by  cartilage, 
this  cartilage  not  being  transformed  into  bone  increases  in  extent 
and  undergoes  molecular  changes,  which  have  been  minutely  de- 
scribed by  M.  Broca.  According  to  him,  as  we  examine  the  carti- 
lage beginning  at  the  epiphysis,  we  find  first  a  layer  of  cartilage 
which  is  but  little  changed,  containing  cells  in  their  normal  state. 
^Nearer  the  diaphysis  we  find  cartilage  perforated  with  small  holes, 
the  cartilage  cells,  instead  of  being  distinct,  being  arranged  in 
longitudinal  groups,  in  other  words,  lying  in  longitudinal  cavities, 
and  flattened  by  mutual  pressure.  'Near  the  diaphysis  bands  of 
fibrous  ^tissue  surround  the  clusters  of  cells. 

While  the  anatomical  changes,  described  above,  are  occurring, 
the  ligaments,  which  unite  the  bones,  become  gradually  lengthened 
and  relaxed,  so  that  there  is  increased  mobility  of  the  bones  upon 
each  other. 

The  deformities  which  occur  in  the  second  stage  vary  in  degree 
in  different  cases,  according  to  the  amount  of  rachitic  softening 
and  tumefaction  of  the  bones,  and  relaxation  of  the  ligaments,  on 
the  one  hand,  and  the  movements  of  the  patient  on  the  other.  If 
the  patient  is  old  enough  to  walk,  the  curvatures  ordinarily  occur 
first  in  the  lower  extremities;  but  if  too  young  to  walk,  in  the 
upper  extremities. 


96  RACHITIS. 

Craniotahes. — Occasionally  the  cranial  bones  in  rachitis  become 
very  much  thinned  and  softened  in  places,  to  which  the  name  of 
craniotahes  has  been  applied.  This  thinning  occurs  most  frequently 
in  the  occipital  bone,  and  sometimes  to  such  an  extent  that  the 
dura  mater  and  pericranium  are  nearly  in  contact.  The  soft  spots 
are  yielding  when  pressed  upon,  and  in  the  cadaver  they  are  seen 
to  be  translucent  when  held  to  the  light.  Craniotahes  has  been  in- 
vested with  considerable  pathological  importance,  chiefly  through 
the  writings  of  Dr.  Elsasser,  more  it  is  now  believed  than  is  war- 
ranted by  the  facts. 

The  changes  in  the  shape  of  the  head  in  rachitis  are  character- 
istic, and  are  so  manifest  as  at  once  to  attract  attention.  The 
growth  of  the  cranium  is  not  retarded  like  that  of  other  parts  of 
the  system,  and  in  some  patients  its  volume  is  greater  than  the 
normal  size.  If  there  is  considerable  cranial  development,  hyper- 
trophy or  hydrocephalus  commonly  coexists.  The  rachitic  skull 
does  not  always  present  the  same  shape.  It  may  be  elongated,  but 
more  frequently  it  approximates  to  a  square  shape.  It  is  more  or 
less  flattened  superiorly,  laterally,  anteriorly,  and  posteriorly.  The 
sutures,  which  are  late  in  closing,  are  commonly  depressed,  while 
the  frontal  protuberances  are  unusually  elevated.  Elevation  of  the 
sutures  in  ridges  has  been  observed  in  exceptional  cases,  as  also 
flattening  limited  to  one  plane  of  the  head,  or  greater  in  one  than 
in  the  others,  so  as  to  destroy  the  symmetry  of  the  cranium. 

The  deformities  of  the  trunk  and  limbs  occurring  in  the  second 
stage  are  interesting.  There  is  lateral  depression  of  the  thoracic 
walls  between  the  second  or  third  and  ninth  ribs,  accompanied  by 
projection  of  the  sternum.  The  shape  of  the  chest  resembles  that 
of  the  prow  of  a  ship,  to  which  Glisson  likened  it,  or  the  breast 
of  a  bird.  This  deformity  is  the  result  of  atmosj^heric  pressure, 
occurring  externally  upon  the  thoracic  walls  during  inspiration, 
at  the  time  when  the  ribs  are  most  softened,  and  least  clastic. 
Depression  of  the  first  and  second  ribs  is  partially  prevented  by  the 
support  which  they  receive  from  the  clavicles.  The  length  of  the 
clavicles  is,  however,  somewhat  diminished,  and  their  curvatures 
increased,  so  that  the  shoulders  approach  each  other.  Below  the 
ninth  ribs  the  thoracic  walls  are  expanded ;  the  corresponding  ribs 
on  the  two  sides  are  more  separated  from  each  other  than  in  their 
normal  state.  The  expansion  of  the  base  of  the  chest  diminishes 
the  convexity  of  the  diaphragm,  and  causes  depression  of  the  liver 
and  spleen. 

The  abdomen  in  rachitis  is  protuberant,  partly  on  account  of  the 


RACHITIS. 


97 


depression  of  the  liver  and  spleen,  partly  on  account  of  the  spinal 
curvatures  and  shortening  of  the  trunk,  but  chiefly  on  account  of 
the  fact  that  in  this  disease  the  intestines  are  distended  with  g-as. 
The  meteorism  gives  rise  to  tympanitic  resonance  on  percussion, 
except  occasionally  over  the  lower  part  of  the  abdominal  cavity, 
where  there  may  l)e  dulncss  from  serous  effusion. 

Spinal  curvatures,  to  which  allusion  has  been  made,  are  common 
in  rachitis.  The}^  are  due  to  softening  of  the  intervertebral  carti- 
lages, and  the  bodies  of  the  vertebrae,  and  to  laxity  of  the  inter- 
vertebral ligaments.  Their  direction  is  commonly  antero-posterior. 
They  are  distinguished  from  the  deformity  of  caries  by  the  absence 
of  an  angular  projection.  Moreover,  except  in  cases  of  long  con- 
tinuance, the  curvature  can  be  removed  by  placing  the  patient  in  a 
horizontal  position,  and  pressing  with  the  fingers  on  the  projecting 
parts.  The  pelvic  bones  also  undergo  change  of  shape.  There  is 
expansion  of  the  upper  part  of  the  pelvic  cavity,  from  the  pressure 
of  the  abdominal  viscera,  corresponding  with  the  expansion  of  the 
lowei'  part  of  the  thorax,  though  not  in  as  great  degree,  while  the 
lower  part  of  the  pelvic  cavity  is  contracted. 

The  bend  of  the  humerus  is  such  in  most  patients  that  its  con- 
cavity looks  inwards  and  forwards,  but  occasionally  it  is  directly 
the  opposite.  The  concavity  upon  the  forearm  corresponds  with  the 


l)alniar  surface  of  the  hand.  The  concavity  of  the  thigh  })resents 
towards  the  median  line  and  a  little  posteriorly.  The  natural  bend 
of  the  femur  being  simply  increased.  The  curvatures  of  the  tibia 
and  fibula  vary  in  difterent  cases.  If  the  infant  has  not  walked, 
7 


98  KACHITIS. 

their  concavity  is  commonly  directed  forwards  and  inwards;  but 
if  it  lias  walked,  outwards  and  backwards.  Occasionally,  the  di- 
rection of  the  l)end  on  one  side  differs  from  that  on  the  other. 

Sd  Stage. — The  third  stage  is  that  of  reconstruction.  After  a 
variable  period,  dejDcnding  on  the  severity  of  the  disease  and  the 
state  of  the  constitution,  the  gelatiniform  substance  becomes  more 
consistent,  and  points  of  calcareous  matter  appear  here  and  there 
within  it.  The  deposit  of  lime-salts  continues,  and  the  newly-formed 
bone  again  becomes  firm  and  unyielding.  It  is  generally  cancellous 
in  places  where  the  original  bone  was  of  this  character,  though  the 
extent  of  the  new  cancellous  structure  is  apt  to  be  different  from 
that  in  the  normal  bone.  Thus  not  only  are  the  epiphyses  cancellous 
in  the  new  as  in  the  original  bone,  but  I  have  seen  the  entire  me- 
dullary cavity  filled  with  cancellous  structure.  The  sub-periosteal 
deposit  is  sometimes  also  transformed  into  cancelli.  This  was  the 
character  of  the  change  occurring  under  the  pericranium  in  one  spe- 
cimen which  I  examined.  Where  the  original  bone  was  compact, 
the  reconstructed  bone  is  usually  of  the  same  character,  as,  for  ex- 
ample, in  the  shafts  of  the  long  bones.  Compact  portions  of  the 
reconstructed  skeleton  have  been  said  to  lack  the  elements  of  true 
bone ;  they  are  osteoid,  according  to  this  theory,  and  not  osseous, 
resulting  from  petrifaction  of  the  gelatiniform  substance.  I  have, 
however,  found  the  elements  of  true  bone  in  the  skeletons  of  two 
individuals  who  had  well-marked  rachitic  curvatures.  The  por- 
tions examined  were  removed  from  the  concavities  of  the  long 
bones,  where  there  had  been  decided  bending  and  thickening  of 
the  shafts  from  the  large  amount  of  rachitic  deposit.  In  both 
specimens  the  osseous  corpuscles  (lacimce)  and  Haversian  canals 
were  easily  demonstrated ;  but  in  both  there  had  been  considerable 
growth  of  the  bones  since  the  rachitic  period,  and  perhaps  the 
portions  which  were  examined  belonged  to  this  subsequent  growth. 
Whether  or  not  true  bone  is  produced  in  the  third  stage  of  rachitis, 
that  is,  from  the  deposit  of  calcareous  salts,  which  immediately 
succeeds  the  softening,  certainly  in  the  subsequent  growth  there 
is  the  formation  of  true  bone. 

Such  is  a  brief  sketch  of  the  changes  which  the  skeleton  under- 
goes in  ordinary  cases  of  rachitis.  An  extreme  degree  of  softening 
may  be  reached  in  four  or  five  months,  or  not  till  the  lapse  of  a 
year  or  more.  The  third  stage,  or  that  of  consolidation,  lasts  one 
or  two  years.  AVhile  in  the  first  and  second  stages  there  is  an  arrest 
of  ossification,  and  a  deficiency  of  calcareous  salts  in  the  system, 


COMPLICATIOXS.  99 

there  is  often  in  the  third  stage,  as  Lebert  has  stated,  an  exube- 
rance of  ossification,  and  a  superabundant  deposit  of  the  sahs  of 
lime,  so  that  the  reconstructed  bone  is  firmer  and  stronger  than 
normal  bone. 

Occasionally,  in  reduced  states  of  system,  the  third  stage  does 
not  occur.  The  bones  remain  very  soft  and  flexible,  consisting 
almost  entirely  of  animal  matter.  This  is  what  has  been  desig- 
nated rachitic  consumption  of  bone.  Such  cases  end  fatally  after 
a  variable  time. 

A  not  unfrequent  accident  in  the  second  period  of  rachitis  is 
fracture  in  the  shafts  of  the  long  bones.  If  there  is  almost  com- 
plete removal  of  the  mineral  substance  of  a  bone,  so  that  the  peri- 
osteum incloses  little  except  the  gelatiniform  deposit,  and  the 
animal  matter  of  the  old  bone,  the  limb  bends  readily,  and  no 
fracture  occurs.  If  there  is  not  so  complete  absorption,  the  weight 
of  the  body  or  muscular  exertion  snaps  rather  than  l^ends  the 
weakened  shaft.  From  the  nature  of  the  fracture,  crepitation 
can  rarely  be  produced.  The  callus  is  not  generally  abundant,  and 
reunion  of  the  bone  is  slow.  Many  cases  of  rachitic  fractures  are 
partial,  portions  of  the  shaft  deprived  of  the  mineral  element  bend- 
ing, while  the  part  which  retains  this  element  is  fractured. 

Rachitis  retards  the  evolution  of  the  teeth.  If  the  disease 
commence  as  early  as  the  fifth  or  sixth  month,  no  teeth  commonly 
appear  till  after  the  age  of  twelve  months ;  if  certain  teeth  have 
appeared  prior  to  the  rachitic  disease,  an  interval  of  several  months 
elapses  before  the  next  are  cut.  Teeth  which  are  developed  during 
the  rachitic  state  are  frail,  and  deficient  in  enamel.  They  become 
black  and  carious  early,  and  loosen  in  their  sockets.  If  there  is 
no  tooth  at  the  age  of  twelve  months,  the  infant  is  probably  ra- 
chitic. The  fontauelles  and  cranial  sutures  remain  open  longer 
than  in  healthy  infants.  The  former  may  not  close  till  the  third 
or  fourth  year,  and  the  latter  not  till  the  second  or  third  year. 
Patency  of  the  anterior  fontanelle  after  the  age  of  twenty  months 
indicates  rachitis. 

Although  the  prominent  and  most  interesting  lesions  of  rachitis 
occur  in  the  bones,  anatomical  changes,  resulting  from  the  dis- 
ease, occasionally  occur  in  the  soft  parts.  The  lymphatic  glands, 
liver,  spleen,  and  some  other  organs  not  infrequently  undergo 
waxy  degeneration,  diminishing  greatly  the  chances  of  recovery. 
Whether  this  degeneration  results  from  the  diathesis  directly,  or 
is  due  to  the  bone  disease,  the  substance  which  is  produced  is  now 


100  EACHITIS. 

admitted  to  be  the  true  waxy  material,  though  for  a  time  denied, 
as  it  does  not  always  give  a  clear  reaction  with  iodine. 

Eachitis  influences  the  future  growth  of  the  skeleton.  The  long 
bones,  though  unusually  thick  and  firm,  do  not  attain  the  normal 
longitudinal  development ;  therefore  the  child  of  ten  years,  who 
has  had  rachitis,  is  scarcely  taller  than  one  at  six  who  has  not  been 
thus  aflected.  In  many  patients  the  curvatures  in  the  course  of 
time  gradually  diminish,  so  that  in  youth  and  maturity  the  body 
is  less  misshapen  than  at  the  age  of  two  or  three  years.  It  is  rare, 
however,  that  the  deformities  entirely  disappear. 

It  is  seen  that  the  anatomical  characters  of  rachitis  resemble,  in 
certain  respects,  those  pathological  processes  which  are  admitted 
to  be  of  an  inflammatory  nature.  The  tenderness,  hypersemia,  pro- 
liferation, and  consequent  thickening  of  the  periosteum,  and  the 
proliferation  of  the  epiphyseal  cartilages,  are  perhaps  inflamma- 
tory, since  they  resemble  more  closely  the  lesions  of  inflammation 
than  any  other  recognized  pathological  state.  The  soft  substance, 
which  i§  produced  so  abundantly  in  places  underneath  the  perios- 
teum and  in  the  spaces  of  the  bone,  is  perhaps  in  part  an  exuda- 
tion, and  in  part  the  animal  matter  which  is  formed  in  the  normal 
development  of  the  bone.  The  immediate  cause  of  the  elimination 
of  the  lime  salts  from  the  kidneys,  and  the  consequent  arrest  of 
ossification  of  the  skeleton,  is  unknown,  but  it  has  been  suggested 
that  as  a  large  proportion  of  the  rachitic  sufter  previously  from 
indigestion  and  diarrhoea,  with  the  formation  of  acids  in  the  pri- 
mse  vise,  especially  the  lactic,  an  acid  in  the  blood  holds  the  lime 
in  solution,  and  hence  its  elimination.  But  however  plausible  this 
theory  may  appear,  it  lacks  demonstration  as  yet. 

Symptoms. — The  patient  in  incipient  rachitis  is  quiet  and  melan- 
choly, shunning  caresses  or  attempts  to  amuse  him,  since  movement 
of  his  body  increases  his  suftering.  He  has  general  tenderness, 
due  in  part  to  the  morbid  state  of  the  periosteum,  and  in  part  to 
hyperesthesia.  The  rachitic  infant,  therefore,  unless  very  mildly 
aflected,  will  evince  anxiety  and  dread  even  at  the  approach  of 
one,  through  fear  of  being  touched  or  moved.  Trousseau  says 
"  this  change  in  the  character  of  the  infant,  the  fear  which  it  ex- 
periences of  seeing  its  suflerings  return,  which  the  pressure  of 
another's  hand  causes,  this  habitual  sadness  impressed  upon  its 
features,  dififers  from  that  which  we  observe  at  the  commencement 
of  other  maladies,  especially  from  that  in  the  prodromic  period 
of  cerebral  fevers.     In  truth,  in  an  infant  over  whom  this  last 


SYMPTOMS.  101 

and  cruel  aftection  is  impending,  we  are  able  to  excite  again  a 
momentary  cheerfulness;  we  are  able,  by  exciting  actively  its 
spirits,  to  make  it  turn  temporarily  from  this  melancholy  languor, 
Avhich  constitutes  its  habitual  state.  It  is  not  thus  in  the  rachitic ; 
the  more  you  desire  to  arouse  it,  the  more  you  solicit  its  move- 
ments, the  greater  will  be  its  impatience.  It  is  indifferent  to  the 
plays  which  it  previously  loved.  This  *  "•*  *  habitual  sadness  in 
an  infant,  who,  with  an  appetite  rather  augmented  than  dimin- 
ished, sensibly  emaciates,  who  has  constantly  acceleration  of  pulse 
coincident  with  profuse  perspiration,  these  symptoms,  I  repeat, 
have  positive  significance  when  the  infant  does  not  cough  or 
present  any  of  the  signs  Avhich  induce  us  to  believe  in  the  occurrence 
of  tubercular  phthisis." 

Febrile  movement,  manifested  by  acceleration  of  pulse,  is  com- 
mon, although,  in  most  cases,  there  is  no  decided  exaltation  of  the 
external  temperature,  perhaps  in  consequence,  in  part  at  least,  of 
the  free  perspiration  to  which  these  patients  are  subject. 

A  bruit  de  soufflet  of  greater  or  less  intensity,  synchronous  with 
the  pulse,  has  frequently  been  heard  in  rachitic  cases,  when  the  ear 
was  applied  over  the  anterior  fontanelle.  Drs.  Fisher  and  Whitney, 
ITew  England  physicians,  first  called  attention  to  this  murmur,  be 
lieving  it  to  be  a  sign  of  chronic  hydrocephalus.  MM.  Rilliet  and 
Barthez  heard  it  in  cases  of  rachitis,  and  therefore  concluded  that 
the  American  observers  had  mistaken  the  rachitic  for  the  hydro- 
cephalic head.  Later  observations  have  established  the  fact  that 
this  murmur  possesses  little  diagnostic  value.  It  is  heard  in 
healthy  as  well  as  diseased  infants.  Dr.  "Wirthgen  detected  it  22 
times  in  52  children,  all  of  whom,  except  4,  were  in  good  health. 
I  have  auscultated  the  anterior  fontanelle  in  29  infants,  who  were, 
with  two  exceptions,  between  the  ages  of  three  and  thirty  months. 
Most  of  them  were  well,  or  with  trivial  ailments,  which  would 
not  affect  the  cerebral  circulation.  In  most  infants  with  a  patent 
fontanelle  a  murmur  can  be  distinctly  heard  synchronous  with  the 
respiratory  act,  and  in  15  of  the  29  cases  no  other  bruit  could  be 
detected,  while  in  the  remainder,  namely  14,  a  bruit  synchronous 
with  the  pulse  was  heard  at  the  fontanelle. 

The  rachitic,  as  stated  above,  are  liable  to  perspirations,  which 
are  profuse  about  the  head  and  neck,  so  as  to  moisten  the  pillow 
on  which  they  lie.  The  resj^iration  is  more  or  less  accelerated  ex- 
'cept  in  the  mildest  cases,  in  consequence  of  the  flexibility  and 
diminished  elasticity  of  the  ribs,  and  the  lateral  depression  of  the 
thoracic  walls,  Avhich  prevent  full  inflation  of  the  lungs. 


102  RACHITIS. 

The  urinary  secretion  is  abundant,  like  the  perspiration.  During 
the  first  and  second  periods  it  contains  a  large  amount  of  the  cal- 
careous salts,  since  the  lime  which  enters  the  system  with  the  in- 
gesta,  and  which,  in  the  normal  state  is  expended  in  the  growth 
of  bone,  is  eliminated  from  the  system  by  the  kidneys.  o 

The  appetite  in  the  beginning  of  rachitis  is  good,  sometimes 
even  better  than  in  health,  but  it  gradually  diminishes,  as  the  dis- 
ease increases  in  severity,  till  it  is  entirely  lost.  Diarrhoea  alter- 
nating with  constipation  is  common.  With  the  continuance  of 
febrile  movement  and  loss  of  appetite,  the  patient  soon  begins 
to  lose  flesh,  emaciation  in  the  second  stage  being  a  prominent 
symptom. 

Since  the  rachitic  patient  sits  or  lies  quietly,  unable  or  disinclined 
to  make  exertion,  the  muscles  become  small  and  flabby  from  dis- 
use. Deposition  of  fatty  matter  may  occur  between  the  primi- 
tive muscular  fasciculi. 

Rachitis  in  the  female  infant  is  attended  by  one  serious  conse- 
quence, namely,  narrowing  of  the  pelvic  cavity,  from  the  thicken- 
ing, change  of  shape,  and  imperfect  development  of  the  pelvic  bones. 
Rachitis,  therefore,  in  the  female  greatly  increases  the  danger  of 
child-bearing,  and  may  render  it  impossible. 

Complications. — Rachitis  is  often  attended  by  certain  serious  com- 
plications, the  most  common  of  which  are  inflammatory  affections 
of  the  respiratory  apparatus.  Bronchitis  is  one  of  the  most  com- 
mon diseases  during  the  age  at  which  rachitis  occurs,  and  even  a 
mild  form  of  it  involves  great  danger  if  the  ribs  are  soft  and  flexi- 
ble or  the  thorax  have  the  rachitic  deformity.  In  these  cases, 
since  full  inflation  of  the  lungs  is  prevented,  collapse  more  or  less 
complete  of  certain  of  the  lobules  is  apt  to  occur,  increasing  the 
amount  of  dyspnoea,  and  therefore  diminishing  the  chances  of  re- 
covery ;  hence  bronchitis  is  very  fatal  in  infants  who  are  decidedly 
rachitic. 

Imperfect  digestion  of  food,  and  unhealthy  alvine  evacuations, 
common  in  rachitic  children,  frequently  cause  diarrhoea,  and,  after 
a  time,  intestinal  inflammation.  The  diarrhoea,  especially  if  it  has 
become  inflammatory,  is  apt  to  be  obstinate  and  dangerous,  the 
patient  becoming  emaciated  and  feeble. 

Internal  convulsions,  the  so-called  laryngismus  stridulus  or  spasm 
of  the  glottis,  has  been  observed  in  so  large  a  proportion  of  cases, 
that  its  occurrence  in  rachitis  must  be  considered  something  more 
than  mere  coincidence.     Elsasser  believed  that  he  had  discovered 


TKEATMEXT.  103 

the  cause  of  the  laryngismus  in  craniotabes,  but  later  observations 
have  failed  to  establish  the  correctness  of  his  views.  Hypertrophy 
of  brain,  and  chronic  hydrocejihalus,  are  also  occasional  complica- 
tions. In  cases  of  great  deformity  of  the  chest  from  rachitis,  in 
which  the  lungs  are  more  or  less  compressed,  the  pulmonary  circu- 
lation is  retarded  and  imperfect.  This  gives  rise  to  congestion  of 
the  right  cavities  of  the  heart,  with  hypertrophy  of  this  organ, 
and  congestion  of  the  hej)atic  veins,  liver,  and  portal  system. 
Congestion  of  the  portal  system  may  be  regarded  as  a  cause  of  the 
diarrhoeal  attacks. 

Diagnosis. — Diagnosis  is  easy  except  in  incipient  or  slight  cases. 
The  lesions  which  pertain  so  largely  to  the  skeleton  are  readily  de- 
tected. Beading  of  the  costo-chondral  articulations  occurs  early, 
and  is  apparent  to  the  sight.  Enlargement  of  the  joints  of  the 
limbs,  arrested  dental  evolution,  the  state  of  the  anterior  fontanelle, 
the  peculiar  shape  of  the  head,  the  sternal  projection,  and  rachitic 
curvatures,  indicate  positively  the  rachitic  state.  Profuse  perspira- 
tion upon  the  head  and  neck,  and  the  general  tenderness  of  the 
patient,  as  evinced  by  his  cries  when  moved  or  disturbed,  are  also 
important  diagnostic  signs. 

Prognosis. — The  prognosis  is  favorable,  as  regards  life,  if  rachitis 
is  recognized  at  an  early  period,  and  properly  treated.  The  vicious 
nutritive  process  may  be  arrested,  and  the  patient  i^ecover  with  but 
slight  deformity.  If  curvature  of  the  long  bones  has  occurred, 
and  the  head  and  thorax  are  misshapen,  the  patient  under  favora- 
ble hygienic  conditions  commonly  recovers  from  rachitis,  but  with 
permanent  deformities. 

If  there  is  that  degree  of  spinal  curvature  in  the  dorsal  region, 
and  depression  of  the  ribs,  that  respiration  is,  habitually,  more  or 
less  accelerated  and  embarrassed,  on  account  of  compression  of  the 
lungs,  the  prognosis  is  unfavorable,  since  bronchial  or  pulmonary 
inflammation,  occurring  in  this  condition,  is  apt  to  be  fatal.  If 
there  is  much  emaciation,  and  especially  if  diarrhoea  is  present,  or 
of  frequent  occurrence,  the  prognosis  should  be  guarded.  In  these 
cases  there  is  probably  waxy  degeneration  of  important  organs, 
which  cannot  be  remedied. 

Treatment. — The  correct  treatment  of  rachitis  is  obvious  when 
we  consider  its  character  and  the  nature  of  its  causes.  The  indi- 
cation is  to  restore  healthy  nutrition.  This  requires  both  hygienic 
and  therapeutic  measures.  The  apartment  in  which  the  child  re- 
sides should  be  dry,  airy,  and  plentifully  supplied  with  light,    lie 


104  SCROFULA. 

should  be  taken  daily  into  the  open  air,  in  order  to  invigorate  his 
system,  but  in  such  a  way  as  not  to  increase  his  suffering,  in  con- 
sequence of  his  general  tenderness.  The  diet  should  be  appropriate 
for  the  age.  It  should  be  bland  and  easy  of  digestion,  and,  at 
the  same  time,  sufficiently  nutritious.  Cleanliness  of  person  and 
apartment,  and  clothing  sufficient  to  protect  from  vicissitudes  of 
temperature,  are  requisite.  The  rachitic  patient  of  the  city  should, 
if  practicable,  be  removed  to  a  well-selected  locality  in  the  country. 

The  medicines  which  are  of  undoubted  efficacy  in  rachitis  are 
cod-liver  oil,  and  the  vegetable  and  ferruginous  tonics.  Cod-liver 
oil  should  be  administered  in  cases  in  which  the  digestive  function 
is  not  seriously  impaired.  If  the  oil  is  not  readily  digested,  if  it 
diminish  the  appetite,  or  if  the  patient  is  affected  with  diarrhoea, 
it  should  not  be  administered.  Positive  harm  may,  under  such 
circumstances,  result  from  its  use. 

The  citrate  of  iron  and  quinine,  wine  of  iron,  iodide  of  iron,  the 
various  preparations  of  cinchona,  columbo,  etc.,  are  the  medicines 
which,  with  or  without  cod-liver  oil,  are  best  calculated  to  restore 
healthy  nutrition.  When  complications  arise,  the  treatment  should 
l)e  modified  to  meet  the  exigencies  of  the  case.  Most  of  the  diseases 
which  occur  as  complications  require  treatment  similar  to  that 
which  is  appropriate  in  their  idiopathic  form,  but  all  measures  of 
a  depressing  nature  should  be  avoided. 


CHAPTER    II. 

SCROFULA. 

The  term  scrofula  (scrofa,  a  pig,  from  the  resemblance  of  the  en- 
larged cervical  glands  of  a  scrofulous  individual  to  a  swine's  neck) 
is  applied  to  a  diathesis  which  is  characterized  by  increased  vulner- 
ability of  the  tissues  (Virchow).  The  nutritive  process  of  the 
tissues  is  readily  disturbed  even  by  trifling  irritants  or  agencies  in 
those  who  possess  this  diathesis,  and  therefore  the  scrofulous  are 
'very  prone  to  hyperplasia  of  the  lymphatic  glands,  and  inflamma- 
tions of  various  parts.  Inflammations  which  can  properly  be  con- 
sidered as  dependent  upon  this  diathesis  are,  for  the  most  part, 
subacute  or  chronic,  and  they  are  apt  to  occur  in  tissues  which. are 


CAUSES.  105 

seldom  inflamed  in  those  who  possess  a  sound  constitution.  Inflam- 
mation of  a  scrofulous  nature  differs  from  ordinary  inflammation 
in  the  fact  of  a  greater  cell  formation,  and  greater  liahility  to 
cheesy  degeneration  of  the  inflammatory  products.  Moreover,  the 
diathesis  often  modifies  those  inflammations  to  which  all  persons 
are  subject  whether  scrofulous  or  non-scrofulous,  as  coryza  or 
bronchitis,  rendering  them  more  protracted  and  less  amenable  to 
the  ordinary  treatment. 

Scrofula  is  a  disease  chiefly  of  infancy  and  childhood.  Manhood, 
especially  the  first  years  of  it,  is  not  entirely  exempt,  but  scrofulous 
manifestations  after  the  age  of  twenty  are  feeble  and  infrequent, 
disappearing  entirely  as  the  individual  advances  towards  middle 
life.     The  diathesis  is  most  active  prior  to  the  age  of  ten  years. 

Causes. — Scrofula  is  congenital  or  acquired.  Parents  who  had 
scrofulous  symptoms  in  early  life,  or  who  are  in  a  state  of  decided 
cachexia,  as  from  cancer,  syphilis,  intermittent  fever,  or  tubercu- 
losis, are  apt  to  beget  scrofulous  children.  Insufficient  nourishment 
of  the  mother  during  a  considerable  part  of  her  gestation,  and 
advanced  age,  and  therefore  feebleness,  of  the  father,  are  occasional 
causes.  ISTear  blood  relationship  of  the  parents  is  recognized  as  a 
cause  by  most  who  have  written  on  this  diathesis,  and  to  this  fact 
has  been  attributed  the  scrofula  of  royal  families,  though  probably 
with  insufficient  proof. 

Again,  those  born  with  sound  constitutions  may  acquire  scrofula 
through  anti-hygienic  influences  in  the  first  years  of  life.  Among 
the  poor  of  New  York  we  often  observe  one  child  in  the  family 
who  presents  scrofulous  symptoms,  wdiile  the  rest  of  the  children 
are  well,  and  in  many  cases  we  are  able  to  trace  back  the  diathesis 
to  some  depressing  cause  or  causes,  which  were  sufficient  to  effect 
the  peculiar  change  in  the  molecular  condition  of  the  tissues  which 
constitutes  this  disease.  Obviously  the  causes  of  acquired  scrofula 
are  quite  numerous.  In  the  infant  it  is  sometimes  produced  by 
insufficiency  or  poor  quality  of  the  breast  milk,  or  the  use  of  artifi- 
cial food  during  the  period  when  breast  milk  is  required.  Too  pro- 
tracted lactation  also,  especially  if  artificial  food  is  almost  wholly 
withheld,  may  cause  it,  as  may  also,  in  those  who  have  passed  be- 
yond the  age  of  lactation,  the  continued  use  of  a  diet  which  is 
deficient  in  nutritive  properties. 

Residence  in  damp,  dark,  and  filthy  apartments  or  streets  may 
also  produce  it.  Hence,  one  reason  of  its  frequent  occurrence 
among  the  city  poor.     Residence  in  a  small,  crowded,  and  imper- 


106  SCROFULA. 

fectlj'  ventilated  apartment  has  been  known  to  produce  it,  even 
with  personal  cleanliness,  and  a  diet  sufficiently  nutritive. 

Scrofula  may  also  be  produced  in  those  previously  robust  and  of 
sound  constitution,  by  diseases  of  an  exhausting  nature.  The  erup- 
tive fevers,  as  smallpox,  measles,  and  scarlet  fever,  if  severe,  occa- 
sionally have  this  result,  or  they  render  active  the  diathesis,  which 
had  hitherto  been  latent.  In  this  city,  where  chronic  entero-colitis 
of  infancy  is  common,  I  have  sometimes  been  able  to  trace  the 
diathesis  to  it. 

Can  a  child  affected  with  scrofula  communicate  it  to  others  ? 
Does  scrofula  possess  a  peculiar  principle,  a  materies  morbi,  which 
is  communicable  to  others  ?  No  one  believes  in  the  infectiousness 
of  scrofala,  but  there  is  a  strong  popular  belief  that  it  is  communi- 
cable by  contact,  and  some  good  pathologists  and  high  authorities 
in  children's  diseases  are  inclined  to  believe  that  the  popular  opinion 
does  have  some  foundation  in  fact.  M.  Bouchut,  who  holds  that 
the  scrofulous  and  tubercular  diatheses  are  identical,  says  of  scrofula 
that  it  has  not  been  shown  to  be  inoculable.  "  ^Nevertheless,  if  its 
contagiousness  has  not  been  demonstrated,  we  are  not  able  to  say 
that  it  will  not  be  some  day.  The  facts  of  vaccinia  followed  by 
impetigo,  by  scrofulous  ophthalmia,  and  enlargement  of  the  cervi- 
cal glands  attributed  to  the  inoculation  of  scrofulous  vaccine  virus, 
and  those  of  the  contagion  of  phthisis  by  constant  cohabitation, 
demand,  at  least  for  the  present,  a  certain  reserve." 

But  scrofula  differs  widely  in  its  nature  from  those  diseases 
which  are  known  to  be  communicable  by  infection  or  contact.  It 
presents  no  analogy  with  them.  "We  would  not  suppose,  apart 
from  observations,  that  a  diathesis  wdiicli  consists  in  such  a  state 
or  constitution  of  the  tissues  that  they  are  easily  wounded,  pos- 
sessed any  inoculable  principle,  and,  in  my  opinion,  observations 
go  to  show  that  no  such  principle  exists.  How  often  do  we  observe 
children  with  scrofulous  coryza,  otorrhoea,  or  scrofulous  cutaneous 
eruption,  associating  with  others  without  communicating  the  dia- 
thesis ? 

Vaccination,  however,  affords  the  best  opportunity  for  determin- 
ing whether  scrofula  is  inoculable,  and  the  very  prevalent  opinion 
of  non-professional  people,  that  it  may  be  communicated  and  es- 
tablished through  this  operation,  should  have  due  weight.  For  it 
may  be  stated,  as  a  rule,  that  a  wide-spread  popular  belief  in  refer- 
ence to  a  disease,  which  has  external  manifestations,  does  have 
some  foundation  in  truth. 


CAUSES.  107 

The  following  are  the  facts  in  reference  to  this  matter: — 

1st.  It  is  the  almost  unanimous  opinion  of  the  most  experienced 
vaccinators  that  pure  vaccine  lymph  taken  from  a  vesicle  prior  to 
the  eighth  daj^  never  communicates  anything  but  vaccinia.  "When 
another  disease,  as  syphilis,  is  communicated  by  the  use  of  the 
lymph,  it  is  through  the  blood,  which  has  been  mixed  with  the 
lymph  by  careless  puncture  of  the  vesicle.  This  opinion,  so  strongly 
established  by  observations,  also  commands  assent  from  its  reason- 
ableness. 

2d.  Vaccination  of  those  wdio  are  decidedly  scrofulous  with 
virus  from  a  healthy  child,  especially  if  the  scab  is  employed,  not 
infrequently  produces  a  sore  which  becomes  covered  with  a  thick 
and  irregular  crust,  consisting  in  part  of  inspissated  pus,  and  the 
sore  is  long  in  healing.  In  the  scrofulous,  also,  impetiginous  erup- 
tions are  apt  to  arise  around  the  vaccine  sore,  and  the  axillary 
glands  to  become  tumefied  on  the  side  corresponding  with  the 
vaccination.  This  gives  rise  to  the  belief  on  the  part  of  friends 
that  impure  virus  has  been  used,  and  scrofula  communicated,  while 
the  fault  is  in  the  constitution  of  the  child  itself.  The  tumefac- 
tion of  the  glands,  and  the  primary  and  secondary  sores,  gradually 
disappear,  in  most  cases,  leaving  no  ill  effects,  and  with  no  subse- 
quent manifestations  of  disease. 

8d.  The  vaccine  crust  from  a  decidedly  scrofulous  child,  as  it 
contains  more  or  less  animal  matter,  and  is  often  pale,  irregular,  or 
broken,  inserted  in  the  arm  of  a  healthy  child,  not  infrequently 
produces  an  immediate  inflammation  with  suppuration,  so  that  the 
vaccine  vesicle,  if  it  forms,  is  soon  broken,  and  an  irregular  sore  and 
crust  result,  which  present  none  of  the  appearances  observed  in  the 
uncomjolicated  vaccine  eruption.  A  simple  inflammation,  produced 
by  the  pus  or  other  products  contained  in  the  scrofulous  scab,  has 
coexisted  with,  and  modified,  the  specific  eruption.  The  sore  heals 
gradually,  and  impetiginous  eruptions  may  occur  around  it,  but  no 
struma  remains  or  is  communicated. 

4th.  Scrofulous  manifestations  sometimes  appear  for  the  first 
time  after  vaccinia,  but  they  appear  also  after  those  analogous  but 
severer  eruptive  fevers,  namely,  measles,  scarlet  fever,  and  small- 
pox. Those  infectious  exanthematic  diseases  which  profoundly 
affect  the  constitution,  it  is  admitted,  may  be  a  co-operating,  if  not 
a  main,  cause  of  scrofula,  and  is  there  anything  unreasonable  in  the 
supposition  that  vaccinia  may  have  occasionally  a  similar  eflfect, 
though  less  frequently  or  in  a  less  degree,  in  proportion  as  it  is 
milder?    From  my  own  observations,  I  am  of  opinion  that  vaccinia, 


108  SCROFULA. 

not  vaccination,  may  occasionally  awaken  to  activity  the  scrofulous 
diathesis,  or,  in  combination  with  other  causes,  may  even  produce 
it  in  those  who  previously  possessed  sound  constitutions.  It  is  a 
well-established  fact,  in  the  etiology  of  diseases,  that  causes  which, 
in  themselves,  are  entirely  inadequate,  or  even  insignificant,  fre- 
quently produce  disease  in  a  system  which  other  agencies  have 
already  j^repared  for  it.  Thus  an  excoriation  gives  rise  to  erysipelas, 
or  a  slight  exposure  to  cold  produces  rheumatism.  And  so  in  those 
cases  in  which  the  friends  have  charged  the  production  of  scrofula 
upon  vaccination,  it  has  seemed  to  me  that  the  most  that  could, 
with  truthfulness,  be  alleged,  was  that  the  constitutional  disease 
which  had  been  produced  by  the  operation,  namely,  vaccinia,  was 
a  subordinate,  but,  under  the  circumstances,  a  sufficient  cause. 

The  following  is  the  most  striking  case  of  the  apparent  commu- 
nication of  scrofula  through  vaccination  which  I  have  met:  D , 

West  Fortieth  Street,  residing  in  a  tenement-house,  had  no  scrofu- 
lous affection,  and  was  considered  healthy  till  the  age  of  eleven 
years.  The  remaining  children  of  the  family  have  never  exhibited 
scrofulous  symptoms.  At  the  age  of  eleven  years  this  boy  was 
vaccinated  from  a  scab,  the  source  of  which  was  not  known,  but  by 
a  physician  whose  practice  was  chiefly  among  the  city  poor.  The 
sore  produced  was  long  in  healing,  and,  before  it  had  healed,  the 
axillary  glands,  and  those  of  the  face  and  neck,  began  to  be 
prominent  and  hard.  From  this  time  to  the  present,  a  period 
of  six  years,  these  glands  have  remained  so  large  as  to  constitute 
a  deformity,  and  certain  other  groups  of  glands,  as  those  in  the 
left  infra-clavicular  region  and  right  groin,  have  undergone  a 
similar  hyperplasia.  Examination  of  the  blood  by  the  microscope 
shows  the  absence  of  leucocythaemia.  This  case,  at  first  view, 
certainly  appears  to  be  an  example  of  the  communication  of  scro- 
fula through  vaccination,  and,  for  a  time,  I  could  interpret  it  in  no 
other  way.  But  when  we  recollect  the  facts  already  stated,  namely, 
the  improbability  of  the  communicability  of  a  diathesis  of  such  a 
nature,  how  frequently  scrofula  is  acquired  by  children  of  the 
tenement-house  population,  solely  through  the  anti-hygienic  condi- 
tions in  which  they  live,  the  large  number  of  scrofulous  children 
in  the  crowded  quarters  of  the  poor,  many  of  which  have  external 
ailments  so  that  the  conditions  of  its  communication  are  present 
if  it  were  in  any  way  contagious,  when,  I  say,  we  recollect  these 
facts,  is  it  not  probable  that  cases  like  this,  which  are  certainly 
rare,  are  to  be  explained  in  the  manner  indicated  above,  and  that 
scrofula  is  not  transmissible  by  vaccination.     The  facts,  therefore, 


ANATOMICAL    CHARACTERS.  109 

if  they  do  not  prove  a  lack  of  contagiousness,  at  least  render  it 
probable. 

Anatomical  Characters. — There  are  no  ascertained  anatomical 
changes  in  the  blood  which  are  peculiar  to  scrofula.  As  long  as 
the  appetite  and  general  health  remain  good,  and  the  local  affec- 
tions have  not  occurred,  the  composition  of  this  fluid  is,  so  far  as 
known,  unaltered.  In  the  cachexia,  which  occurs  when  the  gene- 
ral health  is  impaired,  the  blood  becomes  impoverished,  the  red 
corpuscles  lose  a  portion  of  their  coloring  matter,  and  the  watery 
element  predominates. 

Does  the  glandular  hyperplasia  of  scrofula  produce  an  excess  of 
the  white  corpuscles?  Virchow  says  (Cellular  Pathology,  Lect. 
IX,),  "  During  the  progress  of  an  attack  of  scrofula,  in  which,  if 
the  disease  run  a  somewhat  unfavorable  course,  the  glands  are  de- 
stroyed by  ulceration,  or  cheesy  thickening,  calcification,  etc.,  an 
increased  introduction  of  corpuscles  into  the  blood  can  only  take 
place  as  long  as  the  irritated  gland  is  still,  in  some  degree,  capable 
of  performing  its  functions,  or  still  continues  to  exist ;  as  soon, 
however,  as  the  glands  are  withered  or  destroyed,  the  formation  of 
lymph  cells  likewise  ceases,  and  with  it  the  leucocytosis.  In  all 
cases,  on  the  other  hand,  in  which  a  more  acute  form  of  disturbance 
prevails,  connected  with  inflammatory  tumefaction  of  the  gland, 
an  increase  of  the  colorless  corpuscles  always  takes  place  in  the 
blood."  Although  the  glandular  hyperplasia  occurring  in  scrofula 
increases  the  number  of  white  corpuscles  in  the  blood,  scrofula 
cannot  be  regarded  as  sustaining  any  causative  relation  to  that 
great  and  constant  increase  t)f  white  corpuscles  which  constitutes 
the'  disease  leucaemia ;  for  this  disease,  as  remarked  by  ISTiemeyer, 
.does  not  occur  in  childhood,  when  the  scrofula  is  active,  but  in 
manhood,  when  the  scrofulous  diathesis  has  become  latent. 

Tlie  anatomical  change  which  a  lymphatic  gland,  when  it  be- 
comes the  seat  of  scrofulous  disease,  undergoes,  consists  in  an  ex- 
aggerated production  of  the  lymphatic  cells,  while  an  increase  in 
the  amount  of  stroma  is  quite  subordinate,  or  none  at  all.  The 
hyperplasia  sometimes  occurs  gradually,  and  without  the  signs 
characteristic  of  inflammation ;  in  other  cases  it  presents  all  the 
features  of  a  true  inflammatory  process.  Caseous  degeneration  is 
the  more  apt  to  occur,  the  larger  the  number  of  newly-formed 
cells,  and  the  greater  their  mutual  pressure. 

The  hyperplasia  is  sometimes  primary,  a  direct  result  of  the 
diathesis.  In  other  instances  it  is  secondary  to  some  adjacent  in- 
flammation, the  morbid  process  being  propagated  along  the  lym- 


110  SCROFULA. 

phatic  vessels.  Thus,  while  primary  hyperplasia  of  the  cervical 
glands  is  not  infrequent  in  children  who  have  a  decided  scrofulous 
diathesis,  secondary  hyperplasia  of  these  glands  is  more  frequent. 
It  results  from  eczema  of  the  scalp,  or  face,  or  otitis,  or  any  of  the 
various  forms  of  stomatitis.  And  so  pharvn^itis  often  trives  rise 
to  hyperplasia  of  the  tonsils,  which  are  lymphatic  glands.  The 
scrofulous  nature  of  the  glandular  enlargement  is  apparent  from 
the  tact  that  it  continues  long  after  the  primary  inflammation 
which  gave  rise  to  it  has  abated ;  for  lymphatic  glands  sometimes 
become  tumefied  in  those  who  are  not  scrofulous,  either  from 
direct  injury  or  propagated  inflammation ;  but  the  tumefaction  is 
commonly  less  in  degree,  and  in  most  instances  it  soon  abates 
when  the  exciting  cause  is  removed. 

The  glands  which  most  frequently  undergo  scrofulous  enlarge- 
ment are  the  cervical,  inguinal,  bronchial,  and  mesenteric,  but  in 
those  who  are  highly  scrofulous,  the  glands  in  the  vicinity  of  any- 
protracted  inflammation  are  very  prone  to  hyperplasia,  and  some- 
times become  cheesy.  Thus,  I  have  seen  enlarged  and  cheesy 
glands  in  the  vicinitv  of  bone  which  was  aftected  bv  scrofulous 
ostitis,  or  periostitis. 

Glands  enlarged  by  scrofula  frequently  remain  indolent  for  many 
months  or  years,  undergoing  no  appreciable  alteration,  but  they  are 
liable  to  attacks  of  acute  inflammation,  when  thev  enlarse,  become 
tender,  and  the  sui-rounding  connective  tissue  infiltrated  and  hard. 
Suppuration  is  the  common  result,  and  the  abscess,  if  subcutaneous, 
escapes  through  the  skin,  leaving  a  cicatrix  which  is  permanent. 

More  frequently,  with  proper  therapeutic  and  hygienic  measures, 
the  glandular  hyperplasia  gradually  abates  after  a  longer  or  shorter 
period,  probably  by  fatty  degeneration,  liquefaction,  and  absorp- 
tion of  the  redimdant  cells.  Even  when  suppuration  occurs  in 
certain  of  the  glands,  others,  and  the  majority,  return  to  their  nor- 
mal state  in  this  gradual  way.  Calcification  of  a  gland  has  been 
known  to  occur,  but  it  is  rare. 

In  order  to  complete  the  description  of  the  anatomical  charac- 
ters of  scrofula,  it  would  be  necessarv  to  describe  the  various  in- 
flammations  to  which  the  diathesis  gives  rise.  It  will  sufiice, 
however,  in  this  connection,  simply  to  enumerate  them.  Those 
which  are  most  common  and  of  chief  importance,  occur  in  the 
skin,  mucous  membrane,  connective  tissue,  the  bones  with  their 
periosteal  covering,  the  joints,  and  the  two  important  organs  of 
special  sense,  the  eye  and  ear. 

Stmptoais. — The  scrofulous  diathesis  is  exhibited  by  certain  phy- 


SYMPTOMS.  Ill 

sical  signs,  which  are  present  in  infancy,  but  are  more  manifest  in 
childhood.  In  one  class  of  strumous  children,  they  are  as  follows: 
Form,  tall  and  slender,  quickness  of  movement  and  perception; 
intelligence,  good  ;  skin,  thin  and  semi-transparent,  through  which 
the  superficial  veins  are  distinctly  seen;  features,  delicate;  cheeks, 
habitually  pale  or  florid,  and  flushed  by  slight  excitement;  eyes, 
bright,  with  bluish  conjunctiva;  muscles  and  bones,  slender  in  pro- 
portion to  their  length.  Those  children  who  present  these  pecu- 
liarities are  said  to  have  the  erythitic  form  of  the  diathesis. 

Others  have  what  has  been  designated  the  torpid  scrofulous 
habit,  which  is  characterized  by  softness  and  flabbiness  of  the  flesh, 
distended  abdomen,  large  head,  broad  face,  slow,  languid  move- 
ments, and  an  over-production  of  fat  in  the  subcutaneous  connec- 
tive tissue  in  certain  situations,  especially  the  nose  and  upper  lip. 
Though  typical  cases  can  be  readily  referred  to  one  or  the  other  of 
these  forms,  there  are  many  cases  which  are  intermediate. 

One  of  the  earliest  of  the  scrofulous  manifestations  is  a  subcu- 
taneous cellulitis  crivins:  rise  to  abscesses,  commonlv  not  larse,  with 
little  surrounding  induration,  little  pain,  tenderness,  and  heat,  and 
slow  in  discharging;  in  a  word,  indolent.  The  most  frequent  seat 
of  these  abscesses  is  upon  the  extremities,  but  they  may  occur  upon 
the  scalp  or  elsewhere.  Thej-  gradually  heal  when  the  pus  escapees, 
their  site  being  indicated  for  a  considerable  time  by  the  depression 
and  reddish  discoloration  of  the  skin,  which  orraduallv  returns  to 
its  normal  state.  Ordinarily,  these  abscesses  do  no  harm  apart 
from  the  reduction  of  the  ^reneral  health  which  thev  effect,  but 
when  occurring  in  localities  where  the  connective  tissue  lies  upon 
the  periosteum,  as  upon  the  fingers,  periostitis  may  result,  with  de- 
struction of  the  surface  of  the  bone.  Again,  thrombi  may  occur 
in  the  veins  of  the  inflamed  part,  giving  rise  to  emboli,  embolismal 
pneumonia,  and  death.  Specimens  from  such  a  case  were  presented 
by  me  to  the  Xew  York  Pathological  Society  in  1868. 

The  scrofulous  affections  of  the  skin  often  also  occur  at  an  early 
age,  even  before  dentition.  They  are  more  frequent  in  infancy  than 
in  childhood.  The  most  common  are  eczema  and  impetigo,  and 
of  rarer  occurrence,  ecthyma  and  lupus.  But  all  of  these  may 
occur  in  those  who  are  not  strumous  or  who  do  not  present  the 
characteristics  of  the  strumous  diathesis. 

Scrofulous  affections  of  the  mucous  surfaces  are  scarcely  less  fre- 
quent than  those  of  the  skin.  They  present  the  ordinary  features 
of  mucous  inflammations  of  a  subacute  and  chronic  character. 

Sometimes  they  occur  without  obvious  exciting  cause;  in  other 


112  SCROFULA. 

cases  there  is  an  exciting  cause,  as  exposure  to  cold ;  but  the  in- 
flammation once  established,  continues  on  account  of  the  diathetic 
condition.  It  is  sometimes  a  matter  of  doubt  whether  a  mucous 
inflammation  is  of  such  a  character  that  it  is  proper  to  designate 
it  scrofulous,  especially  if  it  occur  upon  such  surfaces  as  are  often 
the  seat  of  ordinary  inflammation.  If  the  child  has  heretofore 
i:)resented  symptoms  of  scrofula,  if  the  inflammation  is  subacute, 
and  there  is  no  apparent  cause  to  originate  or  sustain  it  apart  from 
the  diathesis,  it  is  probably  of  a  strumous  character.  The  diag- 
nosis is  rendered  more  certain  by  observing  the  effect  of  anti-stru- 
mous  remedies.  The  most  frequent  of  these  inflammations  are 
coryza,  tracheo-bronchitis,  and  conjunctivitis,  the  last  being  a  part 
of  the  more  general  inflammation  of  the  eye.  More  rarely,  sto- 
matitis, pharyngitis,  vaginitis,  and,  according  to  some,  entero-colitis, 
are  of  a  strumous  character.  Coryza  gives  rise  to  snufiling  respi- 
ration, the  formation  of  crusts  around  and  within  the  nares,  and 
excoriation  of  the  upper  lip.  The  tracheo-bronchitis  is  attended 
by  thickening  of  the  mucous  membrane,  increased  production  of 
mucous  and  epithelial  cells,  and  a  loud  tracheal  rale,  accompanying 
each  inspiration. 

Strumous  inflammation  of  the  mucous  membrane  of  the  trachea 
and  bronchial  tubes  is  not  a  very  infrequent  disease  in  this  city. 
It  sometimes  originates  in  a  simple  inflammation  from  cold,  or  the 
tracheo-bronchitis  of  measles,  or  pertussis,  but  it  is  apt  to  continue, 
with  its  rales,  cough,  and  scanty  expectoration,  for  months,  unless 
relieved  by  a  proper  course  of  treatment. 

Among  the  most  common  of  the  strumous  afi'ections,  are  inflam- 
mation of  the  eyelid,  designated  psorophthalmia,  and  that  of  the 
eye  itself.  The  former  is  characterized  by  redness  and  thickening 
of  the  lids,  detachment  of  the  eyelashes,  and  inflammation  and 
altered  secretion  of  the  "  Meibomian  glands ;"  the  latter,  namely, 
strumous  ox)hthalmia,  by  pain,  lachrymation,  photophobia,  and  a 
moderate  degree  of  hyperemia  of  the  attected  organ. 

Inflammations  of  the  external  and  middle  ear  have  their  origin 
very  generally  in  the  strumous  diathesis.  Occasionally  there  is  an 
exciting  cause  of  the  otitis,  as  an  injury,  or  severe  constitutional 
disease  like  scarlet  fever.  Protracted  otitis,  whether  external  or 
internal,  and  especially  that  form  of  it  which  leads  to  ulceration, 
destruction  of  the  ossicles,  and  caries  of  the  petrous  portion  of  the 
temporal  bone,  it  is  proper,  in  a  large  proportion  of  cases,  to  regard 
and  treat  as  strumous. 

Inflammations  of  the  skeleton,  whether  of  the  periosteum,  bones 


SYMi>TOMS.  113 

themselves,  or  the  joints,  are  common  in  childhood.  They  some- 
times occur  without  apparent  exciting  cause,  but  most  frequently 
result  from  injuries  of  a  trivial  character.  Some  of  the  best  ob- 
servers and  highest  authorities,  as  regards  the  surgical  diseases  of 
children,  both  in  this  country  and  Europe,  state  that  they  do  not 
consider  these  aifections  to  be  of  a  strumous  nature;  while  others 
regard  them  as  manifestations  of  struma.  After  carefully  examin- 
ing the  reasons  for  this  variance  in  opinion,  I  am  convinced  that 
the  difference  of  views  in  reference  to  this  matter  occurs  from  a 
different  understanding  of  the  nature  of  scrofula.  Those  who  state 
that  the  aifections  alluded  to  are  not  scrofulous,  believe,  so  f\ir  as  I 
have  been  able  to  ascertain,  that  scrofula  and  the  tubercular  dia- 
thesis are  identical.  As  tubercles  are  not,  as  a  rule,  present  in 
children  who  suifer  from  these  afiections,  it  is  therefore  held  that 
these  afiections  are  not  scrofulous.  If  those  holding  this  belief 
were  told,  or  could  be  made  to  believe,  that  scrofula  is  entirely  dis- 
tinct from  the  tubercular  diathesis,  that  it  is  merely  a  name  applied 
to  a  diathetic  condition  in  which  the  tissues  are  easily  wounded, 
there  would  probably  be  but  one  opinion  as  regards  the  scrofulous 
nature  of  these  inflammations.  For,  as  I  have  often  had  an  op- 
portunity to  observe,  they  occur  in  a  large  proportion  of  cases  from 
very  trivial  injuries,  showing  a  highly  vulnerable  state  of  the 
tissues. 

Holmes,  in  his  useful  and  eminently  practical  Treatise  on  the 
Surgical  Diseases  of  Children,  says  of  one  of  the  most  common  of 
the  affections  alluded  to,  namel}^,  morbus  coxarius :  "  The  affection 
in  question  occurs  very  frequently  in  strumous  children,  a  circum- 
stance which  has  led  to  its  being  denominated  strumous.  *  ^  * 
If  by  strumous  be  meant  a  state  of  the  system  which,  renders  the 
subject  of  it  prone  to  the  deposit  of  tubercle  in  the  viscera,  I  think 
that  there  is  good  reason  for  asserting  that  morbus  coxarius  often 
attacks  children  w^io  are  not  strumous,  i.e.,  who  display  no  such 
tendency  to  the  deposit  of  tubercle."  Still,  Mr.  Holmes  states  "  that 
there  is  that  condition  of  the  system  which  disposes  its  subjects  to 
the  development  of  low  inflammations  of  various  kinds,"  which  is 
almost  the  full  definition  of  scrofula,  as  understood  by  us. 

The  stubbornness  and  frequent  disastrous  consequence  of  scrofu- 
lous inflammation  of  the  skeleton  is  well  known.  I^early  every 
bone,  as  well  as  its  periosteum,  is  liable  to  this  form  of  inflamma- 
tion, but  some  are  more  frequently  afi'ected  than  others.  Inflam- 
mation of  the  bone  may  terminate  by  resolution,  by  the  formation 
8 


114  SCROFULA. 

of  an  abscess,  or,  and  frequently,  by  carious  or  necrotic  destruction 
of  tbe  bone  itself,  l^ecrosis  is  most  apt  to  occur  in  the  shafts  of 
the  long  bones,  caries  in  the  spongy  extremities  of  these  bones, 
and  in  the  spongy  portions  of  the  short  bones.  If  abscesses  form, 
the  pus  may  finally  escape  from  the  system  by  a  tedious  ulcerative 
process,  or,  retained,  may  undergo  cheesy  degeneration.  Scrofu- 
lous arthritis,  if  early  detected  and  properly  treated,  may  resolve, 
leaving  no  ill  effect;  otherwise,  there  is  apt  to  be  suppuration, 
ulceration,  cartilaginous  and  osseous,  and  anchylosis. 

Scrofulous  children  are  perhaps  no  more  liable  to  inflammation 
of  the  internal  organs  than  other  children,  but  the  inflammatory 
products  are  more  liable  to  cheesy  degeneration,  and  the  prognosis 
is  therefore  less  favorable.  The  most  frequent  of  these  inflamma- 
tions, and  the  one  of  chief  interest,  is  pneumonia.  Catarrhal  pneu- 
monia, so  frequent  in  early  life,  whether  primary  or  secondary,  in 
connection  with  measles,  pertussis,  etc.,  is  a  disease  often  involving 
grave  consequences  in  those  who  are  decidedly  scrofulous ;  since, 
instead  of  resolving,  the  affected  lung-tissue  gii'esents  strong  ten- 
dency to  caseous  degeneration,  ending  in  consumption  of  the  lungs 
and  death.  I  have  most  frequently  noticed  cheesy  pneumonia 
during  extensive  epidemics  of  measles,  as  a  complication  or  sequel 
of  this  disease.  It  may  occur  in  those  who  are  not  scrofulous,  if 
the  vital  powers  are  greatly  reduced,  but  it  is  so  much  more  com- 
mon in  the  scrofulous,  that  some  recent  writers  have  designated 
this  form  of  inflammation  by  the  term  scrofulous,  instead  of  cheesy, 
pneumonia.  From  the  fact,  however,  of  its  sometimes  occurring 
in  the  non-scrofulous,  the  term  cheesy  or  caseous,  especially,  too, 
as  it  expresses  the  anatomical  state,  seems  more  appropriate. 

Relation  of  Scrofula  to  Tuberculosis. — It  is  now  almost  uni- 
versally admitted  that  rachitis  is  entirely  distinct  in  its  nature 
from  scrofula,  although,  till  a  recent  period,  some  of  the  best 
writers  upon  diseases  of  children,  as  Barrier,  held  that  it  was  one 
of  the  manifestations  of  the  scrofulous  diathesis.  Although  the 
peculiar  anatomical  changes  in  rachitis  occur  chiefly  in  the  osseous 
system,  Avhich  is  so  often  the  seat  of  scrofulous  disease,  yet  the 
character  of  these  changes  is  so  diflerent  from  those  which  are 
admitted  to  be  of  a  scrofulous  nature,  and  especially  as  a  large  pro- 
portion of  the  rachitic  do  not  present  evidences  of  a  strumous 
diathesis,  struma  and  rachitis  are  justly  regarded  as  distinct  dis- 
eases, and  their  coexistence  in  the  same  individual  as  a  coinci- 
dence- 

Pathologists  and  writers  on  diseases  of  children  are  not  agreed 


RELATION    OF    SCEOFULA    TO    TUBERCULOSIS.  115 

as  to  the  relation  of  scrofula  to  tuberculosis.  Some,  as  M.  Bouchut, 
hold  that  the  scroftilous  and  tuberculous  diatheses  are  identical, 
believing  tubercles  a  late  manifestation  of  scrofula,  while  others, 
among  whom  occur  the  illustrious  names  of  Jenner,  Virchow,  and 
Villcmin,  deny  their  identity,  though  admitting  their  close  rela- 
tionship. Let  us  consider  the  facts,  some  of  which  are  of  recent 
discovery,  which  show  in  what  manner,  or  to  what  extent,  scrofula 
and  tuberculosis  are  related. 

Ist.  In  scrofula  the  lymphatic  glands  are  more  frequently  af- 
fected than  any  other  part,  a  true  hyperplasia  of  their  cellular 
elements  occurring.  This  hyperplasia  occurs  to  a  greater  or  less 
extent  in  the  majority  of  marked  cases,  and,  when  persistent,  is 
the  most  reliable  sign  of  the  diathesis.  The  cells,  which  are  pro- 
duced so  abundantly  in  scrofulous  glands,  are,  to  all  appearance, 
identical  in  character  with  the  cells  of  which  tubercles  are  com- 
posed. In  other  words,  the  physiological  type  of  the  tubercle  cell 
is  the  normal  cell  of  the  lymphatic  gland,  and  the  proliferation  of 
this  cell,  as  we  have  already  stated,  produces  the  enlarged  gland 
of  scrofula.  But  it  is  to  be  observed,  as  showing  the  difierence 
between  scrofula  and  tuberculosis,  that  this  cell  is  never  found  in 
the  affections  admitted  to  be  scrofulous,  in  any  other  situation 
than  in  these  glands,  where  they  exist  normally ;  whereas,  in  tuber- 
culosis, they  are  produced  abundantly,  not  only  in  the  lymphatic 
glands,  but  in  various  organs  and  tissues  throughout  the  system, 
which  contain  no  such  cell  in  their  normal  state.  Moreover,  the 
origin  of  this  cell  in  the  lymphatic  gland  is,  according  to  Virchow, 
difl'erent  in  scrofula  and  tuberculosis.  AVhile  in  the  former  it  is 
produced  by  segmentation  of  the  lymphatic  cells,  in  the  latter  it 
is  produced  from  the  cells  or  nuclei  existing  in  the  connective* 
tissue  of  the  gland,  as  it  is  in  other  situations. 

2d.  It  has  already  been  stated  that  the  products  of  scrofulous 
inflammation  are  very  liable  to  cheesy  degeneration.  In  children, 
indeed,  cheesy  degeneration  more  frequently  results  from  the  scro- 
fulous affections  than  from  any  or  all  other  diseases.  Take,  in 
connection  with  this  fact,  the  very  important  recent  discovery  that 
tubercles  are  caused,  in  a  large  proportion  of  cases,  by  particles  of 
cheesy  matter,  detached  from  the  main  mass,  and  conveyed  to  the 
lungs  or  other  organs,  and  we  see  another  intimate  relation  between 
scrofula  and  tuberculosis. 

3d.  While  the  above  facts  show  the  close  relationship  of  scrofula 
and  tuberculosis,  other  facts  relating  to  their  hereditary  transmis- 
sion show,  in  my  opinion,  their  non-identity.     The  children  of 


116  SCROFULA. 

syphilitic  parents  are  very  apt  to  acquire  thereby  a  scrofulous 
diathesis,  and  be  affected  by  scrofulous  ailments,  while  they  cannot, 
as  a  rule,  be  said  to  possess  the  tubercular  diathesis,  or  exhibit  any 
more  tendency  to  tubercles  than  other  children  who  are  in  a  state 
of  equal  cachexia.  This  does  not  comport  with  the  doctrine  that 
scrofula  and  tuberculosis  are  identical.  Again,  the  infant  of  the 
parent  who  has  advanced  tuberculosis  exhibits  a  great  liability  to 
tubercles,  and  less  in  degree  to  scrofulous  ailments.  If  the  dia- 
thesis of  scrofula  and  tuberculosis  were  identical,  we  would  expect 
that  a  larger  proportion  of  these  infants  w^ould  exhibit  scrofulous 
manifestations,  and  a  smaller  proportionate  number  become  tuber- 
cular, since  scrofulous  ai&ctions  are  so  much  more  frequent  than 
tubercles. 

4th.  As  favoring  the  view  that  there  are  two  diatheses,  writers 
have  stated  the  fact,  that  the  greatest  liability  to  tubercles  is  at 
an  age  when  scrofulous  affections  are  rare,  namely,  from  the  age  of 
twenty  to  thirty  years.  M.  Bouchut  attempts  to  reconcile  this 
fact  with  his  theory  of  one  diathesis,  by  analogical  reasoning, 
which  does  not  seem  to  me  to  be  sound.  He  holds  that  there  are 
distinct  groups  of  manifestations  of  the  diathesis,  according  to  the 
age  or  the  time  of  its  continuance,  as  in  syphilis,  and  that  tubercles 
are  the  last  manifestation.  But  tubercles  may  occur  at  any  age, 
even  in  infants  of  a  few  months.  Indeed,  they  are  more  common 
at  the  age  of  two  or  three  years  than  at  ten  or  twelve.  The  rea- 
soning of  M.  Bouchut  does  not,  therefore,  appear  to  invalidate  the 
argument,  for  how  can  we  consider  tuberculosis  an  advanced  stage 
of  scrofula,  when  it  may  occur  at  any  age  or  at  any  period  of  those 
affected  with  scrofula  ? 

5th.  Recent  investie-ations  demonstrate  that  tuberculosis  is  less 
a  diathesis  than  was  formerly  supposed,  or  than  scrofula  is  admitted 
to  be.  That  there  is,  and  was  previously,  a  tubercular  diathesis  in 
a  majority  who  are  affected  with  tubercles,  cannot  be  denied  ;  but, 
on  the  other  hand,  there  are  those,  and  not  a  few,  who  become 
affected  with  tubercles  from  the  operation  of  local  causes  solely, 
when  there  was  no  diathetic  predisposition  to  them.  Thus,  an 
individual  who  has  never  presented  any  evidences  of  scrofula  or 
tuberculosis,  but  whose  system  is  perhaps  in  a  reduced  state  from 
some  cause,  takes  a  pneumonia,  and  the  inflammatory  products, 
instead  of  undergoing  absorption,  become  cheesy,  and  from  this 
cheesy  substance  tubercles  result  in  the  manner  already  described. 
Local  causes  have  developed  a  tuberculosis  unaided  by  a  diathesis. 
Such  cases  are  not  very  unusual.     Contrast  with  this  the  fact  that 


TROGNOSIS.  117 

iu  the  causation  of  scrofulous  ailments  the  scrofulous  diathesis 
always  plays  a  conspicuous  part. 

6th.  The  following  fact  may  be  inferred  from  the  foregoing,  but 
it  is  so  important  in  this  connection,  as  showing  the  difference  be- 
tween scrofula  and  tuberculosis,  that  it  is  proper  to  consider  it 
under  a  separate  heading.  Scrofula  simply  modifies  the  ordinary 
physiological  or  pathological  processes,  while  in  tuberculosis  there 
occurs,  in  the  tissue  attccted,  a  pathological  process  which  is  pecu- 
liar. Thus  in  tuberculosis  there  is  produced  from  the  connective 
tissue,  or  more  rarely  from  epithelial  cells,  a  cell  which  under  no 
other  circumstances  is  produced  in  these  parts;  whereas  if  scrofula 
aft'ects  the  same  tissues,  there  is  simply  an  increase  in  the  normal 
histological  elements  or  inflammation,  with  inflammatory  products. 

Prognosis. — As  scrofula  may  be  acquired  through  anti-hygienic 
influences,  so  it  may  disappear  or  become  latent  through  influences 
of  an  opposite  character.  Therefore  the  manifestations  of  scrofula 
may  be  limited  to  a  brief  period,  or  they  may  occur  at  intervals 
through  the  whole  of  childhood  and  the  first  years  of  youth. 
When  the  diathesis  is  inherited,  and  fostered  by  unfavorable  cir- 
cumstances, the  scrofulous  affections  appear  earliest,  are  the  most 
varied  and  severe,  and  continue  longest. 

In  most  cases,  with  proper  treatment,  the  prognosis  is  good,  pro- 
vided there  are  no  serious  local  ailments.  Scrofulous  manifesta- 
tions gradually  disappear,  the  diathesis  ceases  or  becomes  latent,  and 
the  health  is  fully  re-established.  Though  the  general  health  is 
restored,  certain  scrofulous  inflammations,  continuing  for  a  certain 
time,  and  reaching  a  certain  grade  of  intensity,  produce  perma- 
nent deformity  or  impairment  of  function.  In  unfavorable  cases, 
death  may  occur  from  exhaustion  due  to  protracted  suppurative 
inflammation,  or  from  tuberculosis  resulting  from  the  cheesy  pro- 
duct of  a  scrofulous  inflammation.  Again,  if  the  function  of  a 
vital  organ  is  permanently  impaired  by  scrofulous  disease,  the  prog- 
nosis of  any  subsequent  inflammatory  affection  of  that  organ  is 
rendered  much  less  favorable. 

Treatment.  Prophylactic. — Measures  designed  to  prevent  scro- 
fula are  impossible  without  the  co-operation  of  willing  and  intelli- 
gent parents.  It  is  obvious  that  the  prevention  of  congenital 
scrofula  requires  the  treatment  of  disease  or  impaired  health  in 
the  parent.  If  parents  should  be  taught  or  should  remember  that 
good  health  in  themselves  is  the  necessary  condition  of  the  inheri- 
tance of  a  sound  constitution  in  the  child,  and  should  adopt  such 


118  SCROFULA. 

therapeutic  and  regimenal  measures  as  would  procure  this,  the 
number  of  cases  of  inherited  scrofula  would  be  materially  reduced. 

As  the  first  years  of  life  are  very  important,  both  for  correcting 
the  diathesis  when  inherited,  and  for  preventing  its  development 
in  those  of  sound  constitution,  care  should  be  taken  that  the  regi- 
men of  the  child  be  such  as  would  in  no  way  produce  deterioration 
of  the  general  health.  The  nursing  infant,  if  the  mother  is  in 
poor  health,  should  be  provided  with  a  healthy  wet-nurse,  for  in 
young  children  the  diathesis  may  be  acquired  solely  by  the  use  of 
food  that  is  scanty  or  of  poor  quality.  Those  old  enough  to  be 
weaned  should  have  plain  and  nutritious  diet,  with  a  proper  ad- 
mixture of  animal  food.  More  or  less  out-door  exercise,  and  a 
residence  in  a  salubrious  locality  with  sufficient  air  and  sunlight, 
are  requisite. 

Curative. — As  scrofula  originates  in  a  state  of  weakness  exist- 
ing in  the  parent  in  the  congenital,  and  in  the  child  in  the  acquired, 
form  of  the  disease,  and  is  characterized  by  feeble  resistance  of 
the  tissues  to  irritating  agents,  the  inference  is  reasonable  that  all 
tonics  have,  to  a  certain  extent,  an  anti-scrofulous  effect  upon  the 
system.  The  ordinary  vegetable  tonics,  and  sometimes  the  ferru- 
ginous, are  indeed  useful  in  the  treatment  of  scrofula.  Employed 
in  connection  with  proper  regimenal  measures,  they  are  sufficient, 
in  many  cases,  to  remove  the  diathesis  after  a  time,  or  render  it 
latent.  Besides  these  medicinal  agents,  which  tend  to  correct  the 
scrofulous  diathesis  by  their  general  tonic  eftect,  there  are  certain 
others  which  experience  has  shown  to  be  beneficial  in  the  treat- 
ment of  scrofulous  affections,  and  which  are,  therefore,  largely 
used.  One  of  these  is  cod-liver  oil,  which  contains  iodine  with 
numerous  other  in2:redients. 

Cod-liver  oil  is  useless  or  nearly  so  in  the  torpid  form  of  the 
diathesis,  which  is  characterized  by  an  increased  deposit  of  fat  in 
the  subcutaneous  connective  tissue,  slow  circulation,  and  sluggish 
muscular  movements.  On  the  other  hand,  in  the  treatment  of  the 
erythitic  form  it  possesses  real  value.  Its  protracted  use  in  such 
cases  does  so  modify  the  molecular  condition  of  the  tissues  that 
they  are  less  liable  to  inflammation,  and  the  diathesis  is,  therefore, 
rendered  milder  or  removed.  From  one  to  three  teaspoonfuls,  ac- 
cording to  the  age,  should  be  given  three  times  daily.  While  we 
frequently  experience  so  much  difficulty  in  administering  it  to 
adults  affected  with  tuberculosis,  and  sometimes  find  it  necessary 
to  discontinue  its  use  on  account  of  its  nauseating  effect,  scrofu- 


TREATMENT.  119 

lous  children  rarely  refuse  to  take  it,  and  it  does  not  seem  to  di- 
minisli  their  appetite. 

Iodine  is  justly  celebrated  as  a  remedy  in  the  treatment  of  scrofu- 
lous aftections,but  it  is  a  qnestion  whether  it  has  not  been  overrated 
as  a  remedy  for  the  diathesis  itself.  Iodine  employed  internally 
is  especially  serviceable  in  glandular  hyperplasia,  and  in  scrofulous 
thickening  and  induration  of  the  connective  tissue  and  periosteum. 
In  general,  it  should  not  be  administered  to  children  in  its  isolated 
state,  on  account  of  its  irritating  properties,  but  one  of  its  com- 
pounds should  be  employed.  The  compounds  which  are  chiefly 
prescribed  in  the  treatment  of  sci'ofula  are  the  iodides  of  starch,  iron, 
potassium,  and  sodium.  If,  as  is  frequently  the  case,  the  patient  is 
pallid,  and  his  appetite  poor,  the  iodide  of  iron  should  be  preferred; 
if  not  in  this  cachectic  state,  the  iodide  of  starch.  Pharmaceutists 
prepare  syrups  of  both  these  iodides,  so  that  they  can  be  readily 
administered  to  the  youngest  child.  The  iodide  of  starch  may  be 
administered  by  dropping  from  one  to  five  drops  of  the  officinal 
tincture  of  iodine  on  a  little  powdered  starch,  and  giving  it  in 
syrup.  These  iodides  are  preferable  to  the  iodides  of  potassium 
and  sodium  for  internal  administration  to  children,  as  they  are  not 
irritating  to  the  mucous  membrane,  and  the  iodine  is  readily  set 
free.  Prof.  Dalton  has,  indeed,  demonstrated  that  the  iodide  of 
starch  is  decomposed  in  most  of  the  liquids  of  the  body,  and  ^the 
iodine  liberated. 

In  this  city  a  large  proportion  of  the  scrofulous  children  are 
cachectic,  and  need  iron,  and  the  iodide  of  iron  is  more  frequently 
employed  than  any  other  iodine  compounds.  In  the  Out-door 
Department  at  Bellevue  it  is  daily  prescribed  for  the  scrofulous 
children,  and  with  the  best  results.  It  is  taken  readily,  and  for 
a  lengthened  period  without  producing  gastric  symptoms.  To  a 
child  of  six  months  we  give  at  this  institution  one  drop  three 
times  daily,  and  to  one  of  two  years  three  drops,  with  or  without 
cod-liver  oil. 

The  internal  use  of  mercury  as  an  antidote  for  scrofula  is  now 
generally  discarded.  Unless,  perhaps,  in  those  cases  in  which  the 
diathesis  is  immediately  dependent  on  syphilis,  its  use  for  this 
purpose,  from  what  we  know  of  its  therapeutic  effects,  would  pro- 
bably be  more  injurious  than  beneficial.  Walnut  leaves,  employed 
in  various  ways,  either  as  a  decoction,  infusion,  wine,  or  extract, 
have  been  highly  extolled  for  the  treatment  of  scrofula,  but  their 
use  has  not  met  with  favor  in  the  profession,  and  comparatively 
few  can  speak  from  their  own  observations  of  their  effect. 


120  SCROFULA. 

Among  the  medicines  which  have  been  from  time  to  time  em- 
l^loyed  for  the  cure  of  scrofula,  some  of  which  have  had  consider- 
able reputation,  but  which  have  nearly  fallen  into  disuse,  may  be 
mentioned  sarsaparilla,  elecampane,  conium,  digitalis,  horseradish, 
and  certain  compounds  of  silver,  gold,  arsenic,  baryta,  and  bro- 
mine. From  what  we  know  of  the  nature  of  scrofula,  it  is  proba- 
ble that  none  of  these  has  any  effect  upon  the  diathesis  or  upon 
scrofulous  ailments,  except  such  as  improve  the  appetite  and  general 
health,  like  horseradish.  The  same  hygienic  measures  are  required 
in  the  treatment  of  scrofula  as  are  demanded  in  the  prophylaxis 
of  it. 

The  scrofulous  affections  require  additional  and  special  treatment. 
It  would  transcend  the  proposed  limits  of  this  paper  to  speak  of 
the  various  measures,  medicinal,  mechanical,  etc.,  which  are  de- 
manded for  their  cure.  I  shall  only  describe  the  treatment  of  the 
affection,  which  is  especially  characteristic  of  scrofula,  namely, 
glandular  hyperplasia. 

It  is  the  common  practice  to  treat  these  glands,  if  they  are  sub- 
cutaneous, by  daily  application  over  them  of  the  officinal  tincture, 
the  compound  tincture,  or  the  compound  ointment  of  iodine.  It 
is  my  opinion,  from  observing  the  effects  of  these  agents,  that  they 
are  too  irritating  for  ordinary  cases.  Applied  daily,  they  cause 
proliferation  of  the  cells  of  the  epidermis,  bo  that  in  two  or  three 
days  the  thickening  of  the  cuticle  is  greatly  increased,  and  its  ex- 
ternal layer  begins  to  exfoliate.  It  has  appeared  to  me  that  what 
we  observe  in  the  epidermis  illustrates,  to  a  certain  extent,  what 
occurs  in  the  gland  underneath,  as  a  result  of  active  counter-irri- 
tation. The  gland  does  not  resolve,  its  superfluous  cells  are  not 
destroyed  and  absorbed,  as  was  desired,  but  the  treatment  tends 
rather  to  increase  the  proliferation  of  the  cells  of  the  gland,  or  the 
formation  in  it  of  true  leucocytes.  We  have  seen  that  a  local  cuta- 
neous inflammation,  as  eczema  or  impetigo,  is  apt  to  cause  the 
neighboring  lymphatic  glands  to  enlarge.  How,  therefore,  can 
we  expect  to  reduce  a  glandular  swelling  by  a  mode  of  treatment 
which  establishes  a  similar  condition.  I  once  produced,  partly  by 
accident,  such  an  amount  of  vesication  over  an  enlarged,  hard, 
and  apparently  somewhat  indolent  gland,  in  an  infant  of  fourteen 
months,  that  for  a  week  I  was  very  anxious  lest  a  sore  would 
result,  which  would  heal  with  difficulty,  or  leave  a  permanent 
cicatrix,  and  yet,  instead  of  dispersion  of  the  glandular  swelling, 
the  pathological  processes  were  so  promoted  that  suppuration  and 
discharge  of  pus  occurred  by  the  time  that  the  cuticle  had  re- 


TREATMENT.  121 

formed.  If  hyperplasia  of  the  lymphatic  glands  could  be  cured 
by  counter-irritation,  it  should  have  been  in  this  case. 

The  correct  mode  of  treating  these  glands,  therefore,  as  regards 
external  measures,  I  hold  to  be,  to  apply  the  iodine  preparations  in 
such  a  manner  that  the  largest  amount  of  iodine  will  reach  the 
glands  by  absorption,  with  little  irritation  of  the  skin.  I  am  not 
prepared  to  state  what  is  the  best  formula  for  the  application  of 
this  agent.  During  the  last  few  months,  we  have  been  attempting 
to  determine  this  in  the  children's  class  at  the  Out-door  Depart- 
ment at  Bellevue,  but  our  statistics  of  cases  are  not  at  present  suf- 
ficiently complete  or  numerous  to  enable  me  to  make  a  positive 
statement.  I  feel  justified,  however,  from  the  observations  already 
made,  in  recommending  the  following  formulae,  as  preferable  to  the 
ofiicinal  preparations  which  are  commonly  employed: — 

1st.     R.  Potas.  iodidi  3j ; 

Ung.  stramouii  ^j.     Misce. 

To  be  rubbed  over  the  gland  several  times  daily.  It  should  not  be 
applied  as  a  plaster,  as  it  is  too  irritating  and  will  vesicate.  I  have 
known  a  glandular  swelling,  which  had  continued  about  three 
months,  to  disappear  in  as  many  weeks,  under  its  use  in  connection 
with  internal  remedies.  Glycerine  may  be  employed  in  place  of 
stramonium  ointment.     It  makes  a  nicer  preparation. 

2d.     R.  Liq.  iodinii  compositi, 
Glycerinse,  equal  parts. 

To  be  applied  three  times  daily  with  thorough  friction,  but  less 

frequently  if  the  skin   becomes   irritated.     In   place   of  Lugol's 

solution,  tincture  of  iodine  may  be  employed,  with  perhaps  a  little 

larger  proportion  of  glycerine.     One  of  the  chief  advantages  from 

the  employment  of  glycerine  with  the  stronger  iodine  preparations 

is  that  it  prevents  to  a  great  extent  the  shrivelling  and  desiccating 

efi^ect  on  the  cuticle,  rendering  it  soft  and  in  a  favorable  state  for 

absorption. 

3d.     R.  Liquoris  iodinii  compositi  §ss  ; 
Aquse  ^xv.     Misce. 

To  be  kept  constantly  upon  the  skin  over  the  gland  by  lint  soaked 
with  it,  over  which  oil-silk  may  be  applied  to  prevent  evaporation. 
4th.  In  the  Medical  Press  and  Circular  of  August  3d,  1870,  J. 
"Waring  Curran  states  that  he  has  used  with  great  success  what  he 
designates  a  new  iodine  paint,  consisting  of  half  an  ounce  of  iodine, 
the  same  quantity  of  iodide  of  ammonium,  20  ounces  of  rectified 
spirits,  and  4  ounces  of  glycerine.     I  have  never  employed  it,  but 


122  TUBERCULOSIS. 

presume  from  its  composition  tliat  it  is  useful.  If  too  irritating, 
it  can,  of  course,  be  diluted. 

Mercurial  ointments  have  been  recommended  by  writers  of  repu- 
tation for  the  treatment  of  these  glands.  I  have  employed  them, 
and  known  them  to  be  employed,  but  cannot  say  that  I  have  ever 
observed  any  benefit  from  their  use  whatever.  In  the  children's 
class  at  the  Out-door  Department  at  Bellevue  we  have  discarded 
them  entirely  for  this  purpose,  although  both  the  citrine  and  white 
precipitate  ointments,  diluted  with  an  equal  quantity  of  lard,  have 
been  used  with  great  apparent  benefit  for  chronic  coryza  of  a 
strumous  nature,  and  also  occasionally  for  external  otitis  of  the 
same  nature. 

In  a  paper  read  at  the  meeting  of  the  British  Medical  Associa- 
tion in  1870,  b}^  Mr.  Jordan,  the  writer  recommends,  as  attended 
with  success,  vesication,  not  over  the  gland,  but  at  a  little  distance 
from  it,  as,  for  example,  behind  the  neck,  for  treatment  of  the  cer- 
vical glands.  But  a  mode  of  treatment  which  seems  so  unlikely  to 
be  beneficial  requires  stronger  proof  of  its  utility  than  has  yet  been 
presented. 

"When  the  gland  becomes  actively  inflamed,  as  indicated  by  in- 
creased heat  and  tenderness,  and  redness  of  the  skin,  applications 
of  iodine  are  no  longer  proper.  They  increase  the  local  disease. 
There  is  no  longer  any  probability  of  resolution  of  the  glands,  and 
poultices  should  be  applied. 


CHAPTER    III. 

TUBERCULOSIS. 

Tuberculosis  occurs  at  any  period  of  life.  It  is,  indeed,  more 
frequent  in  early  manhood  than  previously ;  but  it  presents  pecu- 
liar features  in  children,  and  especially  in  infants.  Like  most  other 
general  diseases,  tuberculosis  has  a  local  manifestation  which  serves 
for  diagnosis.  This  is  a  small,  round,  nearl}'^  transparent  granula- 
tion, designated  tubercle,  which  is  developed  within  a  tissue,  or 
upon  its  surface.  In  certain  situations  it  departs  from  its  typical 
rounded  form,  and  is  more  or  less  flattened.  It  is  firm  to  the  feel, 
and,  when  fully  developed,  varies  in  size  from  a  pin's  head  to  a 
small  pea.    It  has  recently,  in  its  various  phases,  been  studied  with 


TUBERCULOSIS.  123 

great  interest  by  pathologists  in  Europe,  and  to  a  certain  extent  in 
this  country,  and  tlieso  investigations  have  already  thrown  con- 
siderable additional  light  on  the  nature  of  tuberculosis. 

The  statistics  of  tuberculosis,  previously  to  the  last  ten  years, 
were  not  strictly  accurate,  since  cheesy  degeneration,  of  whatever 
part,  was  regarded  by  most  pathologists  as  always  a  tubercular 
lesion,  and  its  presence  in  the  cadaver  was  therefore  considered 
sufficient  proof  that  the  disease  of  which  the  patient  died  was 
tuberculosis,  whereas  it  is  now  known  to  be,  in  many  instances,  a 
degenerated  product  of  simple  inflammation.  I  have  records  of 
the  histories  and  post-mortem  examinations  of  thirty-six  cases  of 
tuberculosis  occurring  under  the  age  of  five  years,  having  rejected 
all  cases  of  cheesy  degeneration  when  not  accompanied  by  other 
evidence  of  tuberculosis.  Thus  caries  of  the  vertebrae,  with  cheesy 
substance  in  the  bony  excavations,  I  have  not  considered  tubercu- 
lar. I  have  rejected  one  case  in  which  three  large  cheesy  bronchial 
glands  lay  in  front  of  the  carious  vertebrae,  inasmuch  as  there  were 
no  tubercles  in  the  lungs  or  elsewhere.  In  another  rejected  case, 
the  only  lesions  were  empyema  of  the  left  pleural  cavity,  hyper- 
plasia, and  cheesy  degeneration  of  the  bronchial  glands,  and  a  single 
large  cheesy  nodule  in  the  right  lung. 

Etiology. — The  tubercular  diathesis  may  be  inherited.  Hence 
the  well-known  fact  of  tubercular  families.  Cases  are  not  infre- 
quent in  which  hereditary  tuberculosis  proves  fatal  before  the 
death  of  the  afiected  parent.  The  offspring  of  a  tubercular  parent 
does  not,  as  a  rule,  have  tubercles  at  birth ;  but  the  tubercular  dia- 
thesis, at  first  latent  as  in  syphilis,  manifests  itself  in  a  few  weeks 
or  months  in  the  formation  of  tubercles,  and  in  the  consequent 
cough  and  emaciation.  In  two  cases,  however,  in  my  collection,  a 
cough  was  observed,  according  to  the  statement  of  friends,  as  early 
as  the  second  or  third  week.  Under  good  hygienic  conditions,  the 
inherited  diathesis  may  remain  latent  or  be  removed.  If  both 
parents  are  tubercular,  the  offspring  almost  necessarily  becomes  so. 

Tuberculosis  frequently  results  from  prolonged  anti-hygienic 
conditions  in  those  previously  healthy  and  of  healthy  parentage. 
It  may  result  from  residence  in  damp,  dark,  and  dirty  apartments, 
from  scanty  or  unwholesome  food,  protracted  and  exhausting  dis- 
eases, in  fine,  from  any  agency  which  gives  rise  to  great  and  con- 
tinued impoverishment  of  the  blood.  Age  is  a  predisposing  cause. 
Tuberculosis  is  comparatively  rare  under  the  age  of  one  year,  while 
it  is  not  uncommon  in  wasted  infants  between  the  ages  of  two  and 
five  years.     This  remark  is  fully  substantiated  by  the  statistics  of 


124  TUBERCULOSIS. 

the  llTursery  and  Child's  Hospital  and  Infant's  Hospital  of  this 
city. 

Is  tuberculosis  propagated  by  infection?  Most  physicians  would 
answer  in  the  negative,  though  in  some  countries,  as  in  Italy,  it 
is  stated  that  the  profession  have  long  regarded  it  as  mildly  infec- 
tious. Every  physician  of  experience  must  have  remarked  the 
frequency  with  which  tuberculosis  occurs  in  those  not  predisposed 
to  the  disease,  but  who  have  been  in  intimate  relation  with  con- 
sumptive patients.  This  has  been  commonly  regarded  as  due  in 
no  way  to  infection,  but  has  been  thought  to  be  a  coincidence,  or 
has  been  attributed  to  an  influence  not  fully  understood,  which  the 
emotions  or  imagination  exerts  in  the  causation  of  diseases.  But 
recent  discoveries  concerning  the  etiology  of  tuberculosis,  which 
will  presently  be  related,  afl:ord  ground  for  the  opinion  which  some 
of  our  best  authorities  in  the  pathology  of  tuberculosis,  as  Wal- 
denburg,  now  hold,  that  minute  particles  exhaled  or  expectorated 
from  the  lungs  may  be  the  medium  of  infection. 

In  December,  1865,  M.  Villemin  read  before  the  Academy  of 
Medicine  of  Paris  and  published  his  celebrated  memoir,  which 
contained  the  results  of  his  experiments  in  inoculating  certain 
lower  animals  with  tubercular  matter.  Since  then  the  fact  has 
been  established  by  many  experiments,  that  tubercle  may  be  pro- 
duced in  the  rabbit  and  other  animals  by  inserting  under  their  skin 
various  pathological  products,  whether  tubercular  or  non-tubercu- 
lar, as  gray  tubercles,  cheesy  products,  thickened  pus,  etc.,  and  by 
inserting  finely  divided  foreign  substances,  not  animal,  as  aniline 
blue,  and  also  by  traumatic  irritations  which  give  rise  to  the  for- 
mation of  inflammatory  products  under  the  skin,  as  the  use  of  a 
seton.  The  coloring  matter,  whether  introduced  alone  or  in  com- 
bination with  a  pathological  substance,  is  found  in  the  tubercle 
which  results  in  the  lung-s  or  elsewhere.  Therefore  it  is  inferred 
tliat  tubercle  in  these  experimental  cases  is  produced  by  minute 
particles  of  the  inserted  substance,  which  enter  the  circulation  and 
are  deposited  in  the  lungs  or  other  organs.  "VYhere  they  are  de- 
posited, inflammation  (formative  irritation)  occurs,  with  prolifera- 
tion of  the  cellular  elements  of  the  part.  This  corpusculation 
produces  the  tubercle. 

The  importance  of  these  discoveries  is  apparent.  Cheesy  sub- 
stances produced  in  the  system,  whether  in  the  lungs,  lymphatic 
glands,  bones — as  in  vertebral  caries — or  elsewhere,  and  also  long- 
retained  purulent  collections,  as  in  empyema,  may  give  rise  to 


ETIOLOGY.  125 

tuberculosis,  provided  particles  of  the  morbid  substance  gain  ad- 
mittance into  the  circulation. 

Blood  extra vasated  in  the  alveoli  of  the  lungs,  and  undergoing 
degenerative  changes,  is  considered  a  cause  of  tuberculosis ;  but 
such  extravasations  are  rare  prior  to  the  age  of  puberty.  Protracted 
inflammation  of  the  air-passages,  as  bronchitis  or  laryngitis,  is 
stated  to  give  rise  to  tubercles  in  certain  cases,  but  it  is  not  easy  to 
see  how  this  could  occur  except  when  the  inflammation  has  ex- 
tended to  the  lungs  or  given  rise  to  cheesy  degeneration  of  the  con- 
tiguous glands.  In  infancy  and  childhood  the  common  cause  is  a 
diathesis  inherited,  or  acquired  through  impoverishment  of  the 
blood  by  previous  disease  or  anti-hygienic  conditions,  or  it  is  in- 
fection of  the  system  from  cheesy  glands  or  purulent  collections. 

Post-mortem  examinations  in  connection  with  these  recent  dis- 
coveries demonstrate  that  the  immediate  cause  of  the  formation  of 
tubercles  in  the  lungs,  spleen,  and  other  viscera,  in  certain  cases,  is 
hyperplasia  and  cheesy  degeneration  of  the  bronchial  and  mesen- 
teric glands,  whether  or  not  this  glandular  affection  is  To  be  con- 
sidered tubercular.  Thus  in  the  last  two  cases  which  I  have  ex- 
amined there  were  minute  transparent  tubercles  in  the  lungs,  some 
becoming  yellow,  evidently  of  very  recent  formation,  and  also  in 
one  of  the  cases  in  the  spleen,  while  in  both  cases  the  bronchial 
glands  were  enlarged  and  cheesy,  and  in  one  also  the  mesenteric. 
In  another  case,  occurring  in  the  Child's  Hospital,  the  bronchial 
and  mesenteric  glands  were  cheesy,  with  all  the  thoracic  and  ab- 
dominal viscera  healthy,  while  there  were  granulations  nearly  the 
size  of  a  pin's  head,  due  to  cell  proliferatioii,  as  ascertained  by  the 
microscope  (tubercular),  in  the  pia  mater  at  the  base  of  the  brain, 
along  its  sides,  and  between  the  hemispheres. 

Cases  are  less  frequent,  but  are  occasionally  met,  in  which  re- 
tained purulent  collections  appear  to  be  the  cause  of  the  formation 
of  tubercles.  Thus,  in  1870,  I  presented  to  the  ISTew  York  Patho- 
logical Society  the  lungs,  containing  minute,  recent  tubercles,  re- 
moved from  an  infant,  who  had  died  when  a  few  months  old.  The 
lungs  were  otherwise  healthy,  and  there  were  no  cheesy  glands,  for 
which  a  careful  examination  was  instituted;  but  in  the  left  thigh 
was  a  large  deep-seated  abscess,  which  had  been  detected  a  month 
before  death. 

Another,  and  probably  the  most  frequent  local  cause  of  tubercu- 
losis, is  cheesy  pneumonia.  Caseous  degeneration  of  the  inflam- 
matory products  is  common  in  young  and  feeble  infants  affected 
with  pulmonary  inflammation,  and  the  supposition  is  reasonable 


126  TUBERCULOSIS. 

that  particles  are  more  readily  detached  from  a  caseous  mass  in  tlie 
lungs  than  in  most  other  situations.  Certainly,  in  this  city,  cases 
are  not  infrequent  of  young  children  presenting  the  history  of 
pneumonia,  cheesy  degeneration,  and  finally  tubercles,  especially 
during  epidemics  of  measles. 

General  Anatomical  Characters  of  Tuberculosis. — Analysis 
of  the  blood  of  tubercular  patients  shows  an  increase  in  the  water, 
albumen,  fats,  and  white  corpuscles,  and  a  decrease  in  the  number 
of  red  corpuscles.  The  fibrin  is  slightly  diminished,  except  in 
cases  complicated  by  inflammation,  in  which  it  may  be  in  excess. 
The  chief  interest,  however,  as  regards  the  anatomical  characters 
of  tuberculosis,  pertains  to  the  tubercle.  The  tubercle  is  as  cha- 
racteristic of  tuberculosis  as  the  eruption  is  of  an  exanthematic 
fever.  It  is  produced,  as  already  stated,  by  a  local  proliferation  or 
corpusculation.     It  is,  therefore,  a  cell-growth,  and  not  a  deposit. 

If  we  examine  with  a  microscope  a  thin  section  of  a  recent 
tubercle,  we  will  observe  in  its  peripheral  portion,  in  which  pro- 
liferation was  active  at  the  time  of  death,  large  mother  cells,  spin- 
dle-shaped fibro-plastic  cells,  and  small  round  cells,  which  have 
been  released  from  the  mother  cells.  This  zone  of  proliferation 
often  has  considerable  extent.  Passing  towards  the  central  portion 
of  the  tubercle,  we  find  these  small  round  cells  in  great  abundance. 
They  represent  a  more  advanced  stage  of  the  tubercle,  since  the 
central  part  is  oldest.  They  are  the  most  numerous  cells  in  the 
tubercle,  and  they  have  been  designated  the  tubercle  cells.  They 
resemble  closely  in  appearance  the  smaller  of  the  white  corpuscles 
of  the  blood,  and  cannot  be  distinguished  from  the  normal  cells  of 
the  lymphatic  glands,  each  consisting  of  a  single  large  nucleus 
surrounded  by  protoplasm.  They  are  among  the  most  fragile  of 
pathological  cells.  The  cells  are  held  together  by  a  transparent 
adhesive  substance,  which  is  firm  and  resisting. 

Every  tubercle  tends  to  undergo  a  molecular  change  by  which 
its  transparence  is  lost.  This  consists  in  a  decay  of  the  cells  and 
the  intercellular  substance.  Granules  of  fat  are  deposited  within 
them,  and  the  cells  shrivel  and  disintegrate.  Fragments  of  cells, 
and  shrunken  cells,  and  cell-nuclei,  are  thus  produced,  which  Lebert 
described  as  the  tubercle  cells,  and  which  were  accepted  as  such  by 
all  observers  till  Virchow  ascertained  their  true  character.  The 
molecular  change  which  I  have  described  commences  in  the  interior 
of  the  tubercle,  and  extends  outward  till  the  whole  tubercle  becomes 
opaque  and  yellow,  and  at  the  same  time  so  friable  as  to  be  readily 


ANATOMICAL    CHARACTERS.  127 

crushed  between  the  fingers.  The  yellow  tubercle  is  therefore  only 
an  advanced  stage  of  the  gray  semi-transparent. 

It  is  evident  that  tubercle  in  its  first  period  possesses  vitality, 
and,  like  all  neoplasms,  has  its  bloodvessels.  These  are  soon  closed 
by  coagula  or  granular  fibrin,  mixed  with  white  blood  corpuscles. 
When  the  tubercle  has  reached  the  yellow  transformation,  its 
vessels  are  no  longer  pervious,  but  it  is  surrounded  by  a  vascular 
zone,  in  which  circulation  continues.  The  subsequent  history  of 
tubercle  is  well  known.  It  is  seldom,  perhaps  never,  absorbed. 
It  softens,  and  henceforth,  as  has  been  said  by  a  German  patholo- 
gist, its  history  is  that  of  an  abscess.  It  is  an  irritant,  producing 
inflammation  in  the  surrounding  tissues,  with  thickening  and 
induration,  and  abundant  production  of  pus  cells,  which  mingle 
with  the  tubercle  elements.  Ulceration  and  discharge  of  the  li- 
quefied substance  upon  one  of  the  free  surfaces  is  the  common 
result.  In  exceptional  cases,  instead  of  softening,  the  tubercle  may 
undero-o  fibroid  defeneration  or  cretification. 

Anatomical  Characters  in  Infancy  and  Childhood. — The  ana- 
tomical characters  of  tuberculosis  in  the  first  years  of  life  vary  in 
certain  particulars  from  the  form  which  they  present  in  the  adult, 
but  after  the  age  of  three  years  the  difterences  are  fewer  and  less 
pronounced  than  previously. 

Tubercular  laryngitis,  so  common  in  the  adult,  is  absent  in  a 
large  proportion  of  cases  under  the  age  of  three  years,  and  when 
present  has  little  intensity;  and  ulceration  of  the  larynx  very 
seldom  occurs.  This  has  been  attributed  to  the  fact  that  there  is 
so  little  expectoration  in  young  children,  the  sputum  being  an 
irritant.  Niemeyer,  however,  does  not  consider  the  sputum  of 
tuberculosis  sufficiently  irritating  to  cause  laryngitis  and  laryn- 
geal ulceration ;  but  the  arguments  in  favor  of  this  mode  of  causa- 
tion, in  my  opinion,  more  than  counterbalance  those  which  have 
been  presei^tecl  against  it. 

I  have  never  met  a  case  of  tubercular  ulceration  of  the  larynx 
or  trachea  in  the  post-mortem  examination  of  young  children,  nor 
do  I  recollect  ever  treating  a  case  in  which  there  was  that  degree 
of  dysphonia  which  indicated  ulceration.  Rilliet  and  Barthez,  in 
more  than  300  necropsies  of  tubercular  cases,  found  no  ulcers  in  the 
larynx  or  trachea  under  the  age  of  three  years  ;  8  cases  between  the 
ages  of  three  and  ten  years,  and  8  between  ten  and  fourteen  years. 
The  ulcers,  whether  seated  in  the  larynx  or  in  the  trachea — and 
they  are  in  most  cases  in  the  former,  since  the  inequalities  upon 
the  surface  of  the  larynx  favor  the  retention  of  the  sputum — are 


128  TUBERCULOSIS. 

commonly  small,  superficial,  round  or  elongated,  and  with  little 
thickening  or  inflammation  of  their  borders.  Occurring  in  the 
folds  of  the  mucous  membrane,  for  example,  around  the  vocal 
cords,  their  form  is  usually  elongated. 

Bronchitis  is  not  infrequent.  This  inflammation  is  due  to,  and 
dependent  on,  the  pulmonary  tubercles,  and  is  therefore  most  in- 
tense in  the  part  of  the  lung  where  the  tubercles  are  most  abundant 
and  furthest  advanced.  Consequently  it  is  more  intense  on  one 
side  than  on  the  other,  and  it  may  be  unilateral.  It  differs  in 
this  respect  from  idiopathic  bronchitis,  which  is  commonly  pretty 
uniform  on  the  two  sides.  It  differs  also  in  the  fact  that  it  is 
sometimes  accompanied  by  ulcerations.  The  ulcers  are  round  or 
elongated  in  the  direction  of  the  axis  of  the  tubes,  and,  like  those 
of  the  larynx  or  trachea,  are  superficial.  Idiopathic  bronchitis  of 
infancy  and  childhood  does  not  cause  ulceration.  Circumscribed 
inflammation  may  attack  a  bronchial  tube,  as,  indeed,  the  trachea, 
and  gives  rise  to  ulceration  and  perforation,  from  the  presence  and 
pressure  of  a  diseased  lymphatic  gland  external  to  the  tube.  This 
subject  will  be  treated  of  hereafter. 

Lungs. — It  is  well  known  that  in  the  adult  tubercles  are  alwavs 
present  in  the  lungs,  if  they  occur  in  any  part  of  the  system.  I 
have  met  two  cases  in  which  the  lungs  w^ere  free  from  tubercles  in 
36  post-mortem  examinations  of  children  who  died  of  tuberculosis. 
One  of  the  two  was  an  infant,  but  its  exact  age  is  not  stated  in  the 
records.  It  had  cheesy  degeneration  of  thymus  and  bronchial 
glands,  enlargement  of  mesenteric  glands,  but  without  cheesy  de- 
generation, and  disseminated  tubercles  in  liver  and  spleen.  The 
other,  fifteen  months  old  at  death,  had  tubercular  meningitis,  with 
numerous  granulations  upon  the  convexity  of  the  brain,  and  the 
other  usual  lesions  of  meningeal  inflammation,  with  bronchial  and 
mesenteric  glands  slightly  enlarged  and  cheesy,  and  one  of  the 
former  softened.  In  one  case,  then,  in  18,  the  lungs  had  escaped 
the  disease.  Rilliet  and  Barthez  state  that  they  found  the  lungs 
non-tubercular  in  47  cases  in  312,  and  Ilillier  did  in  25  cases  in  160. 
In  their  cases,  therefore,  the  lungs  were  exempt  from  tubercles  in 
about  1  case  in  7.  But  it  is  to  be  recollected  that  the  statistics  of 
these  observers  were  prepared  at  the  time  when  all  chees}'  degene- 
rations were  thought  to  be  tubercular,  and  the  bronchial  and 
mesenteric  glands  are  sometimes  cheesy  when  there  are  no  tuber- 
cles or  lesions  referable  to  tuberculosis  in  any  other  part  of  the 
system.  I  have  records  of  two  such  cases,  which  I  reject  from  my 
statistics  of  tuberculosis,  as  there  is  no  evidence  that  the  disease 


LUNGS.  129 

was  anything  else  than  simple  inflammation.  Did  I  include  these 
cases,  my  statistics  would  correspond  with  theirs. 

I'ulmonary  tuhercles  in  children  under  the  age  of  tliree  years 
are,  as  a  rule,  discrete,  and  disseminated  through  the  lungs.  In 
cases  at  this  age,  which  have  advanced  to  a  fatal  termination,  we 
commonly  find  yellow  tuhercles  from  the  size  of  a  pin's  head  to  a 
shot  in  the  different  lobes,  many  still  semi-transparent  if  the  dis- 
ease has  been  of  short  duration,  but  if  protracted  most  of  them 
yellow,  and  here  and  there  one  softened  and  surrounded  by  con- 
densed fibrous  tissue.  Around  the  semi-transparent  or  gray  tuber- 
cles, many  of  which  were  growing,  and  therefore  were  in  the  state 
of  active  cell  proliferation  at  the  time  of  death,  narrow  vascular 
zones  can  often  be  detected  by  the  naked  eye. 

Under  the  age  of  three  years,  tuberculosis  exhibits  but  little 
tendency,  perhaps  none,  to  aflect  the  upper  lobes  sooner  or  in 
greater  degree  than  the  lower. 

The  following  are  the  statistics  relating  to  the  site  of  the  tuber- 
cles in  the  lungs  in  the  cases  which  I  have  examined.  All,  it  is 
to  be  remembered,  were  under  the  age  of  three  years: — • 

Cases. 
Tubercles  disseminated  throughout  the  lungs         .        .         .26 
Tubercles  disseminated  throughout  the  two  upper  lobes        .      3 
Tubercles  disseminated  through  right  middle  lobe  and  left 

lower  lobe  only 1 

Tubercles  disseminated  through  left  upper  lobe  only      .         .       3 
Tubercles  disseminated  (few  and  semi-transparent)  in  left 

lung  only 1 

Tubercles  disseminated  in  three  points  in  right,  and  two  in 

left  lung 1 

No  tubercles  in  lungs 3 

36 

Between  the  ages  of  three  and  fifteen  years,  statistics  show  that 
the  upper  lobes  are  more  liable  to  tubercles  than  the  lower ;  but  the 
difierence  in  liability  is  not  great.  In  many  cases  occurring  in 
this  period,  the  difl:erent  lobes  are  aflected  nearly  simultaneously, 
and  not  very  infrequently  the  upper  lobe  is  the  last  which  is  in 
volved.  In  October,  1866,  I  made  the  post-mortem  examination  of 
a  boy  who  died  in  the  Children's  Service  of  Charity  Hospital,  at 
the  age  of  fifteen  years,  and  small  scattered  tubercles  were  found 
in  the  lower  lobe  of  the  left  lung,  while  all  other  portions  of  these 
organs  were  healthy.  Rilliet  and  Barthez,  who  include  in  the 
same  statistics  all  cases  from  birth  to  the  age  of  fifteen  years,  found 
gray  semi-transparent  tubercles 
9 


130 


TUBERCULOSIS. 


In  the  right  superior  lobe  in 
In  the  right  middle  lobe  in 
In  the  right  lower  lobe  in 
In  the  left  superior  lobe  in 
In  the  left  inferior  lobe  in 

The  same  observers  found  yellow  tubercles  in  the 


Cases. 

63 
43 
55 
65 
54 


Right  superior  lobe  in 40 

Right  middle  lobe  in 28 

Right  inferior  lobe  in 89 

Left  superior  lobe  in 35 

Left  inferior  lobe  in 31 

It  has  already  been  stated  that  tubercle  originates  in  a  circum- 
scribed inflammation.  On  the  other  hand,  tubercle,  especially  when 
softening  commences,  is  itself  an  irritant,  exciting  inflammation 
around  it.  Inflammation  occurring  from  this  cause  is  obviously 
likely  to  be  protracted,  continuing  for  weeks  or  months,  unless  the 
tubercular  matter  is  eliminated  by  ulceration.  The  highly  vascu- 
lar and  delicate  lungs  of  the  young  child  are  very  liable  to  inflam- 
mation when  they  are  the  seat  of  tubercles,  and  as  the  tubercles 
are  disseminated,  the  pneumonia  is  commonly  more  extensive  than 
when  it  occurs  from  ordinary  causes.  In  fifteen,  or  nearly  one- 
half  of  the  cases,  there  was  pneumonia  affecting  portions  of  one  or 
more  lobes,  or  an  entire  lobe.  From  the  extent  and  position  of  the 
solidified  portions,  it  was  obvious  that  in  most  cases  the  inflamma- 
tion originated  from  the  irritating  effect  of  the  tubercular  matter, 
while  in  others  it  was  due  to  hypostatic  congestion,  occurring  in 
consequence  of  the  long-continued  recumbent  position  and  the  fee- 
bleness of  circulation.  In  these  fifteen  cases  the  seat  and  extent 
of  the  inflammation  were  as  follows: — 


Nearly  entire  right  lung  .... 

Nearly  entire  middle  and  lower  lobe 

Entire  left  upper  lobe      .... 

A  considerable  part  of  both  lungs  . 

Posterior  parts  of  both  lower  lobes 

Posterior  part  of  left  lung 

Left  lower  lobe,  and  right  middle  and  lower  lobes 

Left  upper  lobe  (contained  a  large  cavity)  and  posterior  part 

of  left  lower  lobe 

Nodules  of  inflamed  lung  around  tubercles 


Cases. 
3 
1 
3 
1 
4 
1 
1 

1 

3 


The  inflammation  in  about  one-third  of  the  cases  was  due  to  hypo- 
stasis, as  it  occurred  in  depending  portions,  extended  but  little  into 
the  lungs,  and  sustained  no  relation  to  the  amount  of  tubercle.  It 
was  in  the  stage  of  red,  or  more  rarely  of  gray,  hepatization. 


LUNGS.  131 

In  seven  of  the  cases  there  were  pulmonary  cavities  as  large  in 
proportion  as  we  ordinarily  find  in  tuberculosis  of  the  adult.  The 
seat  of  one  was  in  the  right  lower  lobe ;  of  two,  the  left  upper 
lobe ;  of  one,  the  right  upper  lobe ;  of  another,  the  right  lung,  its 
exact  seat  not  stated;  and  in  the  remaining  case  the  cavity,  which 
was  the  largest  of  all,  occupied  the  interior  of  all  three  lobes  on  the 
right  side.  Some  idea  of  the  size  of  these  cavities  may  be  learned 
by  the  following  extracts  from  the  records.  1st  Case. — "  A  small 
superficial  cavity  communicating  on  one  side  with  a  bronchial 
tube,  and  on  the  other  side  with  a  small  circumscribed  collection 
of  pus  in  the  pleural  cavity."  2d  Case. — "Cavity  of  the  size  of  a 
hickory-nut."  3d  Case. — "Cavity  of  the  size  of  a  large  hickory- 
nut."  4th  Case. — "Cavity  three-fourths  of  an  inch  in  diameter." 
5th  Case. — "A  large  abscess."  6th  Case. — "The  cavity  occupied 
nearly  the  whole  of  the  interior  of  the  left  upper  lobe."  7th  Case. — 
"  About  half  the  right  lung  excavated  into  a  cavity  which  ex- 
tended through  the  three  lobes." 

Circumscribed  pleuritis,  produced  by  tubercles  underneath  the 
pleura,  was  observed  in  seven  cases.  It  was  ordinarily  attended 
by  little  exudation  except  the  fibrin,  but  in  one  case  a  suflicient 
amount  of  serum  had  been  exuded  to  compress  considerably  the 
lung.     Pus  was  not  observed  in  any  notable  quantity. 

Emphysema  was  present  in  several  cases,  chiefly  in  the  upper 
lobes,  sometimes  vesicular,  with  fulness  or  bulging  of  the  lung,  an 
ansemic  appearance  of  it,  and  doughy,  inelastic  feel.  In  other 
cases  emphysema  was  interstitial,  producing  little  bladders  of  air 
under  the  pleura,  especially  towards  the  root  of  the  lung,  or  sepa- 
rating the  lobules  by  wedge-shaped  or  irregular  interspaces  filled 
with  air.  In  one  case  air  had  escaped  from  an  emphysematous 
bladder  into  the  right  pleural  cavity,  causing  pneumothorax  and 
collapse  of  the  lung, 

'Next  to  the  lungs,  the  bronchial  glands  are  more  frequently  dis- 
eased than  any  other  organs,  in  the  tuberculosis  of  infancy  and 
childhood.  They  undergo  the  successive  structural  changes  which 
characterize  glandular  inflammations,  namely,  hyperplasia,  and 
more  or  fewer  of  them  cheesy  degeneration  and  softening.  In  the 
state  of  hyperplasia  the  firmness  is  diminished,  and  they  have  a 
pale  flesh-color.  Cheesy  degeneration  commences  in  one  or  more 
points  in  the  gland,  sometimes  in  the  peripheral,  sometimes  in  the 
central  portion,  and  it  extends  till  the  whole  gland  presents  the 
well-known  cheesy  appearance.  When  the  gland  softens,  the  thick 
liquid  presents  a  puriform  appearance,  consisting  of  amorphous 


132  TUBERCULOSIS. 

matter,  fatty  particles,  and  the  shrivelled  and  disintegrated  cells 
of  the  gland.     Soon  pus  cells  occur,  and  their  number  increases. 

Microscopy  shows  no  anatomical  difference  between  the  hyper- 
plasia or  cheesy  degeneration  of  the  lymphatic  glands  occurring 
from  inflammation,  and  that  from  tubercle  ;  but  since  the  bronchial 
and  mesenteric  glands  are  not  often  cheesy  or  greatly  hyperplastic 
from  simple  inflamriiation,  and  are  commonly  not  only  greatly 
enlarged  but  chees}^  in  the  tuberculosis  of  young  children,  we  con- 
clude that  the  inflammation  which  gives  rise  to  this  hyperplasia 
and  degeneration  in  such  cases  is  of  a  tubercular  character. 

Rilliet  and  Barthez  state  that  the  bronchial  glands  were  tuber- 
cular in  249  cases  in  children,  while  the  lungs  were  tubercular  in 
265  cases.  All  cheesy  glands,  it  is  to  be  recollected,  they  consi- 
dered tubercular.  In  4  of  the  36  cases  which  I  have  examined,  no 
record  was  preserved  of  the  state  of  the  bronchial  glands ;  in  one 
case  there  was  no  perceptible  hyperplasia  and  no  cheesy  degenera- 
tion; in  two  there  was  hyperplasia,  but  no  cheesy  degeneration, 
while  in  the  remaining  twenty-nine  cases  there  was  cheesy  degen- 
eration of  more  or  fewer  of  the  enlarged  glands,  or  parts  of  them, 
with  occasional  softening.  In  the  fact  that  the  bronchial  glands 
are  tubercular  and  enlarged,  we  have  an  explanation  in  part  of  the 
fact,  that  the  symptoms  in  the  tuberculosis  of  young  children  differ 
from  those  in  the  adult,  since  Louis  found  the  bronchial  glands 
tubercular  in  only  twenty-eight  per  cent,  of  the  adult  cases  of 
tuberculosis  which  he  examined,  and  Lombard  in  only  nine  per 
cent.  A  gland  pressing  upon  the  recurrent  laryngeal  or  pneumo- 
gastric  nerve,  or  the  trachea,  may  give  rise  to  dyspna-a  and  a  cough ; 
or  on  the  descending  vena  cava  or  one  of  the  vense  innominatse,  to 
congestion  of  the  brain  and  meninges,  intra-cranial  serous  effusion, 
and  even  thrombosis  in  the  cranial  sinuses.  The  fact  that  a  soft- 
ened bronchial  gland  not  infrequently  is  eliminated  from  the  sys- 
tem, by  ulceration,  into  a  bronchial  tube  or  the  trachea,  is  well 
known.  In  one  case  which  I  observed  the  ulceration  had  destroyed 
portions  of  three  of  the  cartilaginous  rings  of  a  bronchus,  and  the 
aperture  was  plugged  by  a  cheesy  fragment  of  a  softened  gland 
Avhich  protruded.  Occasionally,  it  is  stated  by  authors,  the  ulcera- 
tion is  into  one  of  the  large  vessels  of  the  mediastinum,  or  even 
into  the  oesophagus. 

In  no  case  did  I  find  tubercles  in  the  heart  or  pericardium, 
though  they  have  been  observed  in  rare  instances  in  the  latter. 
The  mesenteric  glands  were  enlarged  by  hyperplasia,  and  more  or 
less  cheesy,  in  30  cases;  in  their  normal  state,  to  appearance,  in 


ABDOMINAL    VISCERA.  133 

two  cases,  and  in  the  remaining  four  cases  their  condition  was  not 
stated.  In  most  of  the  cases  the  mesenteric  glands  were  smaller 
and  less  cheesy  than  the  bronchial,  but  in  a  few  instances  they 
were  larger  than  the  bronchial  and  more  cheesy. 

'It  is  a  noteworthy  fact,  as  bearing  on  the  causative  relation  of 
these  glands  to  tubercles,  that  not  infrequently  the  amount  of  hy- 
perplasia and  cheesy  degeneration  of  the  former  was  very  consi- 
derable, while  the  tubercles  in  the  lungs  or  elsewhere  were  small, 
even  minute,  semi-transparent,  and  evidently  of  recent  formation. 

Abdominal  Viscera. — In  children,  tubercles  in  the  solid  organs  of 
the  abdomen  rarely  give  rise  to  appreciable  symptoms,  as  they  are 
small  and  disseminated,  not  impairing  materially  the  function  of  the 
part  in  which  they  are  located.  On  the  other  hand,  peritoneal  and 
intestinal  tubercles,  and  the  enlarged  and  cheesy  mesenteric  glands, 
give  rise  to  symptoms  which  require  description.  The  most  frequent 
seat  of  peritoneal  tubercles  is  upon  the  attached  surface  of  the  peri- 
toneum, where  they  are  formed  from  the  connective  tissue.  They 
are  distinctly  seen  through  the  peritoneum,  and  cause  some  pro- 
minence of  it.  Exceptionally  their  seat  is  upon  its  free  surface. 
Every  portion  of  the  peritoneum,  whether  visceral,  parietal,  or 
omental,  is  liable  to  tubercles,  but  general  tuberculization  of  so 
extensive  a  surface  does  not  occur  in  any  one  case.  The  tubercles 
are  spherical  or  lenticular,  and  most  of  them  small.  Sometimes 
they  are  very  numerous,  but  so  minute  as  to  be  scarcely  visible. 
They  are  gray  or  yellow,  according  to  the  age.  Peritoneal  tuber- 
cles often  produce  circumscribed  peritonitis,  causing  adhesion  of 
opposite  surfaces.  The  tubercles  in  themselves  cannot  be  detected 
by  palpation ;  but  masses  or  jjlaques  composed  of  tubercles  and  in- 
flammatory products  are  sometimes  so  large  that  they  can  be  felt 
through  the  abdominal  walls. 

The  symptoms  of  peritoneal  tuberculosis  are  attributable,  for  the 
most  part,  to  the  peritonitis.  Among  them  may  be  enumerated 
abdominal  tenderness  or  pain,  meteorism,  ascites — usually  slight — 
and  derangement  of  the  bowels,  commonly  diarrhoea.  As  tuber- 
cles in  this  situation  occur,  in  most  cases,  subsequently  to  tuber- 
cles elsewhere,  the  symptoms  which  have  been  described  are  asso- 
ciated with  and  are  subordinate  to  others. 

Stomach  and  Intestines. — The  most  common  seat  of  gastro-intes- 
tinal  tubercles  is  the  small  intestine,  and  more  frequently  its  lower 
portion,  near  the  ileo-coecal  valve,  than  its  upper  or  central.  They 
are  rare  in  the  duodenum  or  contiguous  part  of  the  jejunum.    They 


134  TUBEECULOSIS. 

are  developed  ordinarily  in  the  connective  tissue,  either  that  lying 
under  the  mucous  or  the  serous  surface. 

Gastro-intestinal  tubercles  are  often  accompanied  by  ulceration 
of  the  adjacent  mucous  membrane.  But  in  a  certain  proportion 
of  cases  there  is  probably  no  causative  relation  of  the  tubercles 
to  the  ulcers,  for  ulceration  of  this  membrane  is  not  infrequent  in 
the  tuberculosis  of  children,  when  there  are  no  tubercles  in  the 
walls  of  the  stomach  or  intestines.  The  following  statistics  of 
Rilliet  and  Barthez,  relating  to  this  point,  will  aid  in  an  under- 
standing of  the  symptoms: — 

Tubercles  in  walls  of  stomach,  7  cases,  {  ^'^^  "^^^^•^'  ^  ^^«^^- 

I  without  "     1  case. 

Ulcers  of  gastric  mucous  membrane,  without  gastric  tubercles,  14  cases. 

Tubercles  in  small  intestines,  82  cases,  |  ^^*^  "^^"■''  ^^  ^^'^'• 

(without  "     12     " 

Ulcers  without  tubercles  in  small  intestines,  51  cases. 

Tubercles  in  large  intestine,  15  cases,  -j  ^^*^  ^^'^^^«'  ^^  *^^^^^- 

(without  "      5     " 

Ulcers  in  large  intestine,  without  tubercles,  47  cases. 

The  ulcers  have  vascular,  thickened,  and  infiltrated  borders. 
Their  diameters  vary  from  a  line  to  half  an  inch  or  more,  and  their 
general  form  is  circular,  or,  if  two  or  more  unite,  irregular.  Tuber- 
cular ulcers  of  the  stomach  are  mostly  in  the  great  curvature,  those 
of  the  small  intestines  in  the  ileum  and  lower  part  of  the  jejunum, 
and  those  of  the  large  intestine  in  the  ccecum. 

The  following  table  exhibits  the  state  of  the  principal  abdominal 
viscera  in  the  36  cases: — 

Liver.        Spleen.      Kidneys. 

Tubercular 12  23  1 

Non-tubercular 16  6  21 

Not  stated 8  8  14 

Fatty 5  0  0 

In  no  instance  did  I  observe  tubercular  softening  in  the  abdomi- 
nal organs,  and  a  large  proportion  of  the  tubercles  in  the  liver, 
spleen,  and  kidneys  were  still  in  the  first  stage.  In  the  five  cases 
in  which  the  liver  was  recorded  fatty,  this  state  of  the  organ  was 
obvious  to  the  sight,  as  it  is  in  tuberculosis  of  the  adult.  A 
moderate  excess  of  fat  in  the  heiDatic  cells  may  have  been  present 
in  some  of  the  other  cases,  but  it  was  not  sufiicient  to  be  apprecia- 
ble without  the  microscope.  It  is  to  be  remarked  that  in  the  five 
cases  in  which  the  liver  was  recorded  fatty,  this  organ  contained  no 
tubercles.  The  spleen  is  seen  to  have  been  the  most  frequent  seat 
of  tubercles  of  all  the  viscera,  except  the  lungs.     In  fourteen  cases 


SYMPTOMS.  135 

the  intestines  were  examined;  and  in  five,  tubercles  discovered 
developed  in  the  connective  tissue.  The  intestinal  tubercles  were 
small,  and  ulceration  had  occurred  of  the  mucous  membrane  which 
covered  them. 

The  brain  was  examined  in  fifteen  cases.  In  twelve  cases  the 
amount  of  cerebro-spinal  fluid  varied  from  ^ss  to  v,  by  estimation. 
In  two  others  the  records  state  that  there  was  a  considerable  amount 
of  this  fluid,  the  exact  quantity  not  being  given,  while  in  the  re- 
maining case  congestion  of  the  brain  and  meninges  was  noticed, 
but  nothing  was  recorded  in  regard  to  the  amount  of  cerebro- 
spinal liquid.  The  increase  of  the  cerebro-spinal  fluid  in  tubercu- 
losis is  attributable  to  wasting  of  the  brain,  a  hydrocephalus  ex 
vacuo,  and  in  some  cases  to  passive  congestion  and  serous  transuda- 
tion, due  to  feeble  circulation,  or  obstructed  flow  from  the  pressure 
of  bronchial  glands  on  the  vessels  within  the  thorax,  as  already 
stated. 

Tubercles  were  present  in  the  pia  mater  in  three  cases:  in  two 
with  fibrinous  exudation;  in  the  other  without  fibrin  or  other 
evidence  of  inflammation. 

Symptoms. — The  symptoms  in  tuberculosis  of  children  arise  in 
part  from  the  diathesis,  and  in  part  from  the  tubercles.  Before 
the  period  of  tubercles,  there  are  signs  of  failing  health,  such  as 
loss  of  appetite,  flabbiness  of  the  soft  parts,  or  emaciation,  lassi- 
tude, and  loss  of  strength.  These  symptoms  continue  after  the 
formation  of  tubercles,  and  increase. 

The  features  are  ordinarily  pallid,  but  during  the  paroxysms 
of  fever,  to  which  tubercular  patients  are  subject,  they  may  be 
flushed.  Lividity  of  the  features,  due  to  imperfect  decarboniza- 
tion  of  the  blood,  occurs,  if  there  are  enlarged  bronchial  glands 
which  compress  the  vessels  within  the  thorax,  or  if  there  is  ex- 
tensive pulmonary  tuberculization,  or  pulmonary  tuberculization, 
whether  extensive  or  not,  which  is  complicated  by  capillary  bron- 
chitis or  pneumonia. 

The  skin  is  nearly  natural,  or  it  loses  its  flexibility  and  softness, 
and  becomes  dry  and  rough.  In  some  patients  there  is,  at  times, 
general  or  partial  furfuraceous  desquamation  of  the  skin,  due  to 
exaggerated  development  of  the  epidermis.  Children,  like  adults, 
notwithstanding  the  general  dryness  of  the  surface,  are  liable  to 
perspirations  at  night  and  in  sleep.  This  symptom  is  less  frequent 
at  the  commencement  than  at  an  advanced  period,  and  in  acute 
than  in  chronic  cases,  in  the  very  young,  namely,  those  under  three 
or  four  months,  than  in  older  children.     It  is  more  abundant  about 


136  TUBEECULOSIS. 

the  head  and  limbs  than  elsewhere,  and  is  sometimes  confined  to 
these  parts. 

Anasarca  is  not  infrequent.  It  sometimes  arises  from  obstructed 
circulation,  in  consequence  of  compression  of  the  thoracic  vessels 
by  enlarged  lymphatic  glands ;  in  other  cases  it  is  due  to  dimin- 
ished plasticity  of  the  blood,  a  result  of  the  tubercular  cachexia. 
The  latter  is  the  more  common  cause.  It  is  not  an  important 
symptom,  on  account  of  the  small  amount  of  serous  transudation, 
and  the  character  of  the  parts  in  which  it  occurs. 

Emaciation,  already  alluded  to,  is  early,  constant,  and  progres- 
sive. Under  the  age  of  six  or  eight  months  it  is  less  marked  than 
in  older  children,  many  preserving  considerable  rotundity  of  fea- 
tures and  form  even  in  advanced  tuberculosis.  The  failure  of  the 
strength  corresponds  in  amount  and  progress  with  the  emaciation. 
Slight  at  first,  and  exhibited  only  by  a  degree  of  lassitude,  it  gra- 
dually increases,  till  for  weeks  before  death  the  little  patient  is 
fatigued  by  the  ordinary  muscular  movements,  and  is  disposed  to 
keep  quiet. 

The  nervous  system  is  not  ordinarily  affected  except  in  cases  of 
intra-cranial  tubercles.  In  acute  tuberculosis,  or  tuberculosis  com- 
plicated by  severe  inflammation,  there  may  be  agitation  and  deli- 
rium, especially  at  night. 

In  most  patients  the  mucous  membrane  of  the  buccal  cavity 
presents  its  normal  appearance,  with  the  exception  of  a  moist  fur 
upon  the  tongue,  and  a  paler  hue  than  normal  of  its  surface  gene- 
rally. In  acute  tuberculosis,  and  in  cases  complicated  by  inflam- 
mation, the  tongue  is  sometimes  dry  and  brown.  The  appetite 
may  be  normal  till  the  close  of  life,  or  it  is  j)Oor  or  changeable. 
Occasionally  it  is  increased,  although  the  disease  is  progressing. 
The  bowels  are  regular  or  relaxed.  Diarrhoea  may  be  a  prominent 
symptom,  even  when  there  are  no  intestinal  tubercles  or  ulceration. 
Meteorism  and  fulness  of  the  abdomen  are  common. 

Fever,  constant,  but  usually  with  evening  exacerbations,  is  rarely 
absent.  It  continues  for  weeks  or  months.  During  the  exacerba- 
tion the  pulse  rises  to  120,  140,  or  even  to  180  beats  per  minute, 
and  there  is  a  corresponding  exaltation  of  the  temperature,  which 
in  the  latter  part  of  the  day,  without  inflammatory  complication, 
ranges  from  100°  to  102°  or  103°.  The  fever  is  a  symptom  of 
diagnostic  value  as  regards  the  nature  of  the  disease,  though  it 
does  not  indicate  the  seat  of  the  tubercles. 

In  addition  to  the  symptoms  noAv  described,  there  are  special 
symptoms,  due  to  tuberculization  of  the  different  organs.    In  young 


SYMPTOMS.  137 

children,  on  account  of  the  fact  ah-eady  referred  to,  namely,  the 
tendency  to  a  generalization  of  tubercles,  there  is  apt  to  be  a  blend- 
ing of  the  symptoms  which  arise  from  different  organs,  but  with 
care  it  is  not  difficult  in  most  instances  to  isolate  and  refer  them 
to  their  proper  source.  The  following  are  the  symptoms  which 
arise  from  tuberculization  of  the  more  important  organs.  1st.  En- 
CEPHALON.  The  symptoms  produced  by  tubercles  of  the  encephalon 
vary  according  to  their  seat  and  size,  and  the  structural  changes  in 
surrounding  parts  to  which  they  give  rise.  Meningeal  tubercles, 
which  are  located  for  the  most  part  in  the  meshes  of  the  pia  mater, 
and  by  preference  along  the  course  of  the  small  arteries,  are  ordi- 
narily small,  not  more  than  a  line  in  diameter,  and  they  may 
remain  latent  for  a  considerable  time.  In  the  majority  of  cases, 
however,  they  sooner  or  later  cause  meningitis,  the  symptoms  of 
which  are  well  known  and  need  not  be  described.  But  tubercles 
in  this  situation  do  sometimes  give  rise  to  symptoms  when  there  is 
no  meningeal  inflammation.  They  occasion  congestion  of  the  sur- 
rounding vessels,  and  serous  transudation-,  and  if  developed  on  the 
under  surface  of  the  pia  mater  they  may  produce  symptoms  by 
encroaching  upon  and  irritating  the  brain ;  for  they  are  sometimes 
so  much  imbedded  in  the  convolutions  that  careful  examination  is 
required  in  order  to  determine  that  they  are  meningeal,  and  not 
cerebral.  Among  these  symptoms  may  be  mentioned  headache, 
frontal  or  occipital,  sometimes  intermittent,  nausea,  melancholy, 
and  in  certain  cases  the  symptoms  produced  by  the  serous  transu- 
dation. 

The  symptoms  of  cerebral  are  in  part  similar  to  those  of  menin- 
geal tubercles,  but  in  most  cases  others  of  a  neuropathic  character 
are  present,  which  serve  for  differential  diagnosis.  The  differences 
as  regards  the  symptoms  of  dift'erent  patients  affected  with  cerebral 
tubercles  are  attributable  in  part  to  the  fact  that  their  size  and 
rapidity  of  growth  vary,  but  more  to  the  difference  in  their  seat; 
for  any  part  of  the  brain  may  be  the  seat  of  tubercles,  though  cer- 
tain portions,  as  the  cerebellum,  are  more  frequently  affected  than 
others. 

The  child  with  cerebral  tubercles  is  quiet,  but  irritable  and  easily 
excited.  Delirium  is  not  common,  but  many  before  the  close  of 
life  exhibit  a  degree  of  mental  dulness.  The  headache,  common 
in  cases  of  cerebral  as  well  as  meningeal  tubercles,  may  be  nearly 
general,  or  it  is  frontal,  parietal,  or  occipital,  according  to  the  seat 
of  the  tubercles.     It  is  often  lancinating,  often  intermittent. 

Clonic  convulsions  occur  towards  the  close  of  life.     Exception- 


188  TUBERCULOSIS. 

ally  they  are  among  the  earliest  symptoms.  Observations  have 
failed  to  establish  any  relation  between  the  seat  of  the  tubercles 
and  the  localization  of  the  convulsions.  The  convulsions  may  be 
unilateral,  while  the  tubercles  are  in  both  hemispheres ;  or  general, 
while  the  tubercles  are  on  one  side  only. 

The  severity  and  duration  of  the  convulsive  attacks,  and  the 
frequency  of  their  occurrence  in  tuberculosis  of  the  brain,  vary 
greatly  in  different  patients.  They  have  been  attributed  to  soften- 
ing of  the  cerebral  substance,  which  sometimes  occurs  immediately 
around  the  tubercles,  to  local  congestions  excited  by  them,  and  also 
to  serous  effusion  in  the  ventricles.  The  convulsions,  sooner  or 
later,  end  in  paralysis  or  coma. 

Contraction^  or  tonic  convulsion  of  certain  muscles,  is  sometimes 
observed.  Its  most  frequent  seat  is  the  muscles  of  the  back,  and 
of  one  or  both  of  the  lower  extremities.  It  is  a  late  symptom.  It 
occurs  in  those  cases  in  which  there  is  softening  around  the  tuber- 
cles, and  usually  in  the  muscles  of  the  opposite  side. 

Paralysis  is  also  a  late,'  but  not  an  unfrequent  symptom.  It  is 
preceded  by  headache,  and  sometimes,  as  already  stated,  by  con- 
vulsions. Occurring  as  a  symptom  of  tuberculosis  of  the  brain,  it 
is  due  either  to  pressure  on  a  cranial  nerve,  or  to  compression  and 
perhaps  softening  of  the  cerebral  substance.  The  paralysis  may  be 
paraplegic,  commencing  as  feebleness  of  the  lower  extremities,  and 
increasing  until  it  becomes  complete,  or  a  more  or  less  complete 
hemiplegia.  In  paraplegia  due  to  tubercles  of  the  brain,  the  cere- 
bellum is,  as  a  rule,  their  seat,  while  paralysis  of  one  side,  or  of 
certain  muscles  of  one  side,  indicates  tubercles  of  the  opposite  cere- 
bral hemisphere ;  but  there  are  exceptions.  Paralysis  of  the  third 
cranial  nerve  gives  rise  to  ptosis,  of  the  sixth  to  paralysis  of  the 
external  motor  nerves  of  the  eye,  and  therefore  to  internal  stra- 
bismus. 

Feebleness  or  loss  of  vision,  inequality,  oscillation,  and  finally 
dilatation  of  the  pupils,  are  not  infrequent  symptoms  of  tubercu- 
losis of  the  brain,  and  they  possess  great  diagnostic  value.  Atrophy 
of  the  optic  nerve,  causing  amaurosis,  sometimes  results  from  tuber- 
cles as  well  as  other  tumors  of  the  brain.  Atrophy  of  this  nerve 
occurs  not  only  when  the  tubercles  are  so  located  as  to  press  on  the 
optic  tract,  in  which  case  the  explanation  is  apparent,  but  also,  in 
certain  patients,  when  the  tubercles  are  in  other  parts  of  the  brain. 
In  these  last  cases  it  is  thought  by  Brown-Sequard  and  others  that 
the  imperfect  nutrition  of  the  nerve  is  due  to  contraction  of  its 
nutrient  vessels,  produced  by  the  tubercles  through  reflex  action. 


BRONCHIAL    GLANDS.  139 

111  tuberculosis  of  tlio  brain,  symptoms  pertaining  to  the  respira- 
tory, circulatory,  and  digestive  systems  arc  either  absent  or  are 
quite  subordinate  to  those  of  a  neuropathic  character.  Slowness 
of  the  pulse,  with  or  without  intermittence,  has  sometimes  been 
observed,  and  it  is  therefore  a  symptom  of  some  diagnostic  value. 
Towards  the  close  of  life  both  pulse  and  res2')iration  are  apt  to  be 
accelerated.  Vomiting,  constipation,  and  retraction  of  the  abdo- 
men, which  are  so  common  in  meningitis,  are  only  occasional 
symptoms. 

Bronchial  Glands. — During  the  progress  of  tuberculosis,  hyper- 
plasia, cheesy  degeneration,  and  softening  may  occur  of  various 
lymphatic  glands  throughout  the  body,  but  the  bronchial  and 
mesenteric  are  not  only  those  which  are  most  frequently  affected, 
but  they  are  the  only  glands,  unless  in  exceptional  instances,  which 
materially  increase  the  danger  or  give  rise  to  special  sj^mptoms. 
These  symptoms  either  have  a  mechanical  cause,  namely,  the  pres- 
sure exerted  by  the  enlarged  glands  on  contiguous  parts,  or  they 
are  due  to  softening  of  the  glands  and  consecutive  inflammation 
and  ulceration. 

The  following  are  the  principal  symptoms  due  to  compression. 
Some  of  them  are  not  infrequent ;  others  are  rare.  Compression 
of  the  pulmonary  veins  retards  the  flow  of  blood  from  the  lungs  to 
the  left  auricle,  giving  rise  to  congestion,  and,  in  extreme  cases, 
oedema  of  the  lungs,  with  sanguineous  extravasations  into  the  lung 
substance,  congestion  of  the  right  cavities  of  the  heart,  hepatic 
veins,  and  of  the  systemic  capillaries  generally.  Compression  of 
the  pneumogastric  nerve,  or  of  the  recurrent  laryngeal,  which  is 
the  motor  nerve  of  the  laryngeal  muscles,  produces  a  cough  which 
is  apt  to  be  spasmodic,  and  modifies  the  voice.  The  cough  resem- 
bles that  of  pertussis,  and  has  been  mistaken  for  it,  but  it  is  not  so 
violent  or  protracted.  The  voice,  clear  and  natural  at  first,  becomes 
by  degrees  hoarse  or  feeble  from  deficient  innervation  of  the  laryn- 
geal muscles. 

An  enlarged  gland,  or  mass  of  glands,  lying  against  the  trachea 
or  one  of  the  bronchial  tubes  (this  may  occur  with  tubes  up  to  the 
third  or  fourth  division),  and  pressing  its  walls  inward,  obviously 
obstructs  more  or  less  the  current  of  air.  If  there  is  considerable 
obstruction,  a  loud  sonorous  rale  is  produced,  which  is  heard  dis- 
tinctly at  a  distance  from  the  chest,  obscuring  other  rales.  It  is 
loudest  when  the  patient  is  agitated,  and  it  sometimes  intermits. 
Feeble  respiratory  murmur,  dyspnoea,  and  a  cough  are  not  infre- 
quent in  bronchial  phthisis.     Diminished  intensity  of  the  respira- 


140  TUBERCULOSIS. 

tory  murmur  is  general  or  partial,  according  to  the  seat  of  the  com- 
pression. It  has  been  most  frequently  observed  at  the  summit  of 
the  lungs.  In  certain  patients  this  symptom  is  not  constant,  the 
respiration  being  for  a  time  feeble  and  then  normal.  The  dyspnoea 
may  be  a  prominent  and  distressing  symptom,  the  alee  nasi  dilating, 
and  the  infra-mammary  region  sinking  with  each  inspiration.  The 
cough  which  occurs  when  a  gland  presses  on  the  trachea  or  bron- 
chial tube,  is  due  to  the  tracheitis  or  bronchitis  to  which  the  pres- 
sure gives  rise.  If  ulceration  occur  at  the  point  of  pressure,  the 
cough  continues  as  long  as  the  ulcer  remains.  Compression  of  the 
large  veins  within  the  thorax,  which  return  blood  from  the  head 
and  upper  extremities,  causes  more  or  less  congestion  of  these  parts, 
with,  perhaps,  transudation  of  serum  in  the  subcutaneous  cellular 
tissue,  and  within  the  cranium.  Rarely  a  softened  gland  by  ulcera- 
tion gives  rise  to  other  symptoms  than  those  mentioned,  namely, 
hemorrhage  by  ulceration  into  a  vessel,  or  pleuritis  or  pneumonitis 
if  the  ulceration  is  towards  the  lungs. 

Improvement  in  the  condition  of  the  patient  affected  with  bron- 
chial phthisis  is  not  unusual.  It  may  be  permanent,  but  in  most 
patients  it  is  temporary,  so  that  in  a  few  weeks  or  months  the 
symptoms  are  as  severe  as  before.  The  improvement  is  due  to  soft- 
ening and  elimination  of  a  gland  which  had  given  rise  to  symp- 
toms by  its  mechanical  effect,  or  by  the  inflammation  which  it  had 
excited. 

Physical  Signs. — These  are  absent  or  obscure  in  the  inciyuent 
disease,  when  the  glands  are  small,  and  they  are  most  marked  in 
those  cases  in  which  the  glands  are  so  large  as  to  press  on  the 
thoracic  walls,  since  the  glands  then  become  the  medium  for  the 
transmission  of  sounds  to  the  ear.  The  part  of  the  thorax  against 
which  they  most  frequently  press  is  the  dorsal  vertebrae,  from  the 
first  to  the  sixth,  and  each  side  of  the  vertebrae,  and  less  frequently 
the  upper  third  of  the  sternum.  The  physical  signs  are  dulness  on 
percussion  over  the  interscapular  space,  and  perhaps,  though  to  a  less 
extent,  over  the  upper  part  of  the  sternum,  and  bronchial  respira- 
tion in  the  same  situations.  Occasionally  a  bruit  can  be  detected, 
due  to  the  pressure  of  a  gland  on  one  of  the  large  vessels  of  the 
chest. 

Lungs. — A  cough  is  one  of  the  earliest  and  most  persistent  of 
the  symptoms  of  pulmonary  tuberculosis.  It  is  so  rarely  absent, 
that  those  of  largest  experience  do  not  meet  with  more  than  one 
or  two  such  cases.  It  varies  in  severity  and  frequency.  If  the 
tuberculosis  is  acute  and  its  course  rapid,  the  cough,  even  from  its 


PHYSICAL    SIGNS.  141 

comincncerncnt,  is  frequent,  so  as  to  weary  the  patient  and  deprive 
him  of  needed  rest.  But  in  ordinary  cases,  namely,  when  the  din- 
ease  is  chronic,  the  cough  commences  gradually,  attracting  little 
attention  by  its  infrequency,  but  becoming  more  frequent  and 
painful  as  the  disease  advances. 

Ordinarily  the  cough  is  dry  in  the  first  weeks  or  months,  but  it 
becomes  looser  in  the  course  of  the  disease,  from  the  greater  amount 
of  bronchial  inflammation.  In  exceptional  instances  the  cough 
has  a  spasmodic  character,  like  that  produced  by  pressure  of  an 
enlarged  bronchial  gland  on  the  pneumogastric  or  recurrent  laryn- 
geal nerve.  This  occurs  from  the  accumulation  of  viscid  mucus 
in  one  or  more  of  the  bronchial  tubes,  usually  in  dilated  portions 
of  them,  from  which  it  is  with  difliculty  expectorated. 

The  respiration  in  pulmonary  tuberculosis  is  accelerated  in  pro- 
portion to  the  degree  of  tuberculization.  Tuberculization  of  a 
considerable  part  of  both  lungs  gives  rise  to  dyspnoea,  especially 
when,  as  is  ordinarily  the  case,  bronchial,  pulmonary,  or  pleuritic 
inflammation  has  supervened.  Pneumonitis  or  pleuritis  gives  rise 
to  the  expiratory  moan,  and  as  these  inflammations,  when  induced 
by  tubercles,  are  protracted,  this  symptom  may  continue  for  weeks 
or  months. 

Patients  under  the  age  of  six  years  do  not  expectorate,  or  but 
rare\y.  After  this  age  expectoration  is  not  common  in  the  com- 
mencement of  pulmonary  tuberculosis,  but  in  the  confirmed  disease 
it  is  a  pretty  constant  attendant  of  the  cough.  Hpemoptysis  is  also 
rare  under  the  age  of  six  years,  and  less  frequent  subsequently  than 
in  the  adult.  It  is  most  apt  to  occur  in  those  cases  in  which  there 
is  already  passive  congestion  of  the  lungs,  produced  by  the  pressure 
of  enlarged  bronchial  glands  in  the  manner  already  described. 
Patients  old  enough  to  make  known  the  subjective  symptoms, 
sometimes  complain  of  fugitive  pains  under  the  sternum  or  between 
the  shoulders. 

Physical  Signs. — In  young  children  the  physical  signs  of  in- 
cipient pulmonary  tuberculosis  are  wanting,  or  are  so  obscure  as 
not  to  be  readily  recognized.  This  is  due  to  the  small  size  and 
dissemination  of  the  tubercles.  In  older  children,  because,  as  a 
rule,  the  tubercles  are  aggregated,  and  are  more  frequently  at  the 
apices  of  the  lungs  than  elsewhere,  as  in  the  adult,  the  physical 
signs  api^ear  early,  and  are  readily  recognized.  In  the  advanced 
disease,  whether  in  infancy  or  childhood,  when  inflammation  and 
more  or  less  destruction  of  the  lung  substance  have  occurred,  the 
physical  signs,  so  far  from  being  obscure,  enable  us  in  most  cases, 


142  TUBEECULOSIS. 

in  connection  witli  the  history,  to  make  an  immediate  and  positive 
diagnosis. 

In  most  children  affected  with  pulmonary  tuherculosis  the 
irregular  and  imperfect  expansion  of  the  lungs  produces  by  de- 
grees changes  in  the  shape  of  the  thorax,  which  are  apparent 
on  inspection.  In  some,  the  lungs  being  habitually  imperfectly 
inflated,  the  obliquity  of  the  ribs  is  increased,  and  the  thorax 
consequently  elongated,  while  its  antero-posterior  and  transverse 
diameters  are  diminished.  This  obviously  increases  the  convexity 
or  arch  of  the  diaphragm,  so  that  this  muscle  sometimes  lies  against 
the  thoracic  walls  as  high  as  the  ninth  or  even  eighth  rib.  If  the 
costal  cartilages  are  yielding,  there  is  anterior  flattening  of  the 
chest  and  depression  of  the  sternum;  if  they  are  firm,  on  account 
of  the  more  advanced  age,  the  chest  remains  circular. 

Another  shape  of  the  thorax  is  not  infrequent  in  feeble  tuber- 
cular children,  especially  infants,  who  have  suffered  from  repeated 
attacks  of  bronchitis.  It  occurs  also  in  the  non-tubercular,  if  the 
conditions  which  favor  it  are  present.  The  conditions  are,  on  the 
one  hand,  feebleness  of  the  patient,  with  diminished  force  of  respi- 
ration and  impaired  resiliency  of  the  ribs;  and,  on  the  other,  ob- 
struction by  mucus  of  one  or  more  of  the  bronchial  tubes.  Occlu- 
sion, more  or  less  complete,  of  a  bronchial  tube,  and  consequent 
obstruction  to  the  current  of  air,  produces  a  corresponding  degree 
of  collapse  in  the  portion  of  lung  to  which  the  tube  leads.  The 
portions  which  collapse  are,  in  most  cases,  the  lower  lobes,  and  the 
thin  anterior  margins  of  the  upper  lobes.  This  causes  lateral  de- 
pression of  the  lower  ribs,  except  such  as  are  pressed  outward  by 
the  abdominal  viscera,  and  an  anterior  projection  of  the  lower  part 
of  the  sternum.  The  shape  of  the  thorax  in  these  cases  differs 
from  that  in  rachitis,  in  the  fact  that  the  lateral  depression  does 
not  extend  to  the  uj^per  ribs,  nor  does  the  upper  part  of  the  sternum 
project. 

Certain  precautions  should  be  observed  in  examining  the  chest 
by  percussion  and  auscultation.  The  child  should  sit  or  recline, 
with  the  arms  and  shoulders  in  the  same  position,  and  the  axis  of 
the  trunk  straight.  Inclination  of  the  trunk  to  either  side,  raising 
or  depressing  a  shoulder,  may  produce  an  appreciable  difference  in 
the  two  sides  as  regards  the  physical  signs.  Percussion  of  the  two 
sides  should  be  practised  at  the  same  stage  of  respiration.  A 
slight  difference  in  the  degree  of  resonance  does  not  afford  proof  of 
disease,  unless  it  is  observed  at  different  examinations ;  for  in  feeble 
children  it  often  happens  that  all  portions  of  the  lungs  do  not  ex- 


PLEURA.  143 

pand  alike,  so  that  where  we  liave  noticed  sliglit  dulness  at  one 
visit,  it  may  by  the  next  have  disappeared,  or  even  at  the  same 
visit  if  forcible  inspirations  are  excited. 

The  physical  signs  ascertained  by  palpation,  auscultation,  and 
percussion  are,  as  in  the  adult,  vocal  fremitus,  bronchial  respiration, 
bronchophony,  and  dulness  on  percussion.  In  those  cases  in  which 
the  tubercles  are  mainly  at  the  apices  of  the  lungs,  diminished  ex- 
pansion of  the  infra-clavicular  region  is  observed  during  inspira- 
tion, and  this  part  of  the  thoracic  wall  is  permanently  depressed, 
so  that  the  clavicles  are  unusually  prominent.  If  there  is  emphy- 
sema, this  flattening  does  not  occur,  or  is  slight.  Dulness  on  per- 
cussion, though  more  frequently  observed  in  the  infra-clavicular 
region  than  elsewhere,  may  be  present  in  different  isolated  places. 
If  pneumonia  supervene,  the  dulness  not  infrequently  extends  over 
a  considerable  part  of  one  lung.  The  crack-pot  sound  is  often 
observed  on  percussion,  but  it  possesses  no  diagnostic  value.  It 
can  be  produced,  when  there  is  no  pulmonary  disease,  by  percussing 
over  a  bronchus. 

Bronchial  respiration  and  bronchophony  are  important  signs,  as 
indicating  solidification  of  the  lung,  but  they  do  not  show  whether 
the  solidification  is  tubercular  or  pneumonic,  or  the  two  conjoined. 
This  must  be  determined  by  the  history  of  the  case,  the  extent  of 
surface  over  which  these  signs  are  heard,  and  their  persistence. 
When  the  tubercles  begin  to  soften,  and  the  lung  tissue  breaks  up, 
moist  rales  appear,  often  hoarse  and  gurgling,  obscuring  the  bron- 
chial respiration.  A  cavity  in  the  lung,  or  pneumothorax,  is 
attended  by  the  same  physical  signs  as  in  the  adult. 

Pleura. — Little  need  be  said  in  reference  to  the  symptoms  and 
physical  signs  of  tuberculosis  of  the  pleura,  since  this  aftection  is 
in  most  instances  associated  with  tuberculosis  of  the  lungs,  and  is 
not  distinguishable  from  it.  But  now  and  then  the  pleural  tuber- 
cles are  numerous  and  large,  giving  rise  to,  symptoms,  while  those 
of  the  lungs  are  small,  few,  and  without  symptoms,  or  attended  by 
symptoms  which  are  quite  subordinate.  Either  the  costal  or  vis- 
ceral portion  of  the  pleura  may  be  the  seat  of  tubercles.  They  are 
developed  directly  under  the  pleura,  or  upon  its  free  surface.  They 
are  very  apt  to  occur  in  the  newly-formed  connective  tissue  which 
results  from  pleuritis.  Those  located  upon  the  free  surface,  or 
under  the  costal  pleura,  rarely  soften,  while  those  under  the  visceral 
pleura  sometimes  soften  and  cause  ulceration.  Occasionally  nu- 
merous aggregated  tubercles  form  a  firm  continuous  layer  upon  the 
surface  of  the  pleura,  preventing,  if  upon  the  visceral  pleura,  full 


144  TUBEKCULOSIS. 

expansion  of  the  lung.  This  may  give  rise  to  a  degree  of  diilness 
on  percussion,  and  feebleness  of  the  respiratory  murmur.  Ordi- 
narily, however,  in  this  form  of  tuberculosis,  the  symptoms  and 
physical  signs,  so  far  as  any  are  observed,  are  due  to  the  pleuritic 
inflammation  which  the  tubercles  excite. 

Stomach  and  Intestines. — The  symptoms  in  tuberculosis  of  the 
stomach  and  intestines  vary  according  to  the  seat  and  stage  of  the 
tubercles. 

Tubercles,  whether  gastric  or  intestinal,  are  not  at  first  accom- 
panied by  symptoms,  or  the  symptoms  are  obscure  and  ill-defined. 
S3'"mi3toms  arise  when  inflammation  occurs  in  the  adjacent  tissues. 
Diarrhoea  is  one  of  the  most  common  and  persistent  of  the  symp- 
toms. The  alvine  discharges  are  brown  and  thin,  and  sometimes 
in  advanced  cases  very  oft'ensive.  They  may  be  streaked  with 
blood  which  has  escaped  from  the  ulcers.  Intestinal  tubercles,  de- 
veloped immediately  underneath  the  peritoneal  coat,  sometimes 
cause  local  peritonitis,  usually  of  little  extent.  This  gives  rise  to 
circumscribed  pain,  tenderness,  and  more  or  less  meteorism. 

Diagnosis. — It  is  evident  from  the  foregoing  description  of 
symptoms  that  the  diagnosis  of  incipient  tuberculosis  is  much 
more  difl&cult  in  children  than  adults.  Before  commencing  the 
examination,  it  is  advisable  to  learn  the  hereditary  tendencies  of 
the  family  and  the  history  of  the  patient,  especially  as  regards 
antecedent  diseases  or  debilitating  agencies,  and  the  duration  of 
the  symptoms. 

Tuberculosis  of  the  encephalon  is  diagnosticated  with  more 
difficulty  than  that  of  the  thoracic  or  abdominal  organs ;  but 
certain  of  these  organs  are  in  most  cases  tubercular  at  the  same 
time,  and  the  knowledge  of  the  fact  that  they  are  aftected  aids  in 
the  diagnosis  of  the  disease  of  the  brain  or  its  meninges.  Among 
the  symptoms  which  possess  diagnostic  value  may  be  mentioned 
'  cephalalgia  and  more  or  less  fever,  with  exacerbations  in  the  com- 
mencement of  the  disease,  and  at  a  more  advanced  period  strabis- 
mus, inequality  or  irregular  action  of  the  pupils,  impairment  of 
vision,  retraction  of  the  head,  and  convulsive  movements  or 
paralysis. 

In  certain  cases  careful  observation  and  discrimination  of  symp- 
toms are  requisite,  in  order  to  determine  whether  they  arise  from 
intra-cranial  tubercles,  or  from  congestion  of  the  brain  caused  by 
obstruction  in  the  venous  circulation  by  the  pressure  of  enlarged 
bronchial  glands. 

The  diagnosis  of  bronchial  phthisis,  when  the  glands  are  still 


DIAGNOSIS.  145 

small,  is  necessarily  uncertain,  on  account  of  the  absence  of  symp- 
toms. When  thoy  have  increased  in  size  and  are  so  located  as  to 
press  on  the  pneumogastric  or  recurrent  lar^mgeal  nerve,  producing 
the  spasmodic  cough  already  described,  the  diflf'erential  diagnosis 
between  that  disease  and  pertussis  may  be  made  by  attention  to 
the  following  facts :  Bronchial  phthisis  occurs  singly,  and  is  non- 
contagious, while  pertussis  occurs  as  an  epidemic,  and  with  evi- 
dences of  contagion.  There  are  no  successive  stages,  namely,  those 
of  catarrh,  paroxysmal  cough,  and  decline,  as  in  that  disease,  and 
the  cough,  though  paroxysmal,  is  short,  and  without  hoop  or 
vomiting. 

In  feeble  children,  with  inherited  tubercular  diathesis,  emacia- 
tion, sweats,  and  a  chronic  cough,  with  the  absence  of  pulmonary 
symptoms,  should  excite  suspicions  that  the  bronchial  glands  are 
involved.  The  evidence  is  almost  conclusive  if  the  cough  becomes 
paroxysmal,  and  there  is  a  loud,  persistent,  tracheal,  or  bronchial 
rale. 

In  certain  of  the  patients  affected  with  this  form  of  the  disease, 
we  have  seen  that  the  prominent  symptoms  are  due  to  compression 
of  one  or  more  of  the  large  vessels  in  the  chest.  Compression  of 
these  vessels,  and  consequent  retarded  circulation,  may  be  con- 
fidently referred  to  enlarged  bronchial  glands,  since  aneurism, 
carcinomatous  or  other  tumors,  which  would  produce  a  similar 
result,  are  very  rare  before  puberty.  Sometimes  the  diagnosis  is 
rendered  certain  by  the  physical  signs  observed  by  auscultation, 
and  percussion  over  the  sternum  and  the  interscapular  space.  The 
condition  of  the  external  glands  should  also  be  observed,  as  those 
of  the  axilla,  neck,  and  groin. 

The  diagnosis  of  pulmonary,  though  more  readily  made  than 
that  of  intra-cranial  and  bronchial  tuberculosis,  is  often  difficult 
and  uncertain.  This  is,  in  part,  explained  by  the  fact  that  the 
tubercles  are  so  frequently  disseminated,  while  emaciation  and  a 
chronic  cough  are  not  infrequent  from  other  causes  than  tubercles. 
Rachitis,  intestinal  worms,  dentition,  simple  tracheal  or  bronchial 
inflammation,  may  be  attended  both  by  a  chronic  cough  and 
emaciation.  Caution  is  therefore  requisite  in  order  to  avoid  a 
grave  error  in  diagnosis.  Precipitancy  in  the  diagnosis  of  doubtful 
cases  is  worse  than  indecision,  and  it  is  often  best  to  postpone  an 
expression  of  opinion  as  to  the  nature  of  the  disease  till  the  case 
has  been  observed  for  a  few  days. 

The  significance  and  importance  of  the  symptoms,  physical  signs, 
and  other  facts  on  which  a  diagnosis  must  be  based,  have  already 
10 


146  TUBERCULOSIS. 

been  sufficiently  pointed  out.  It  is  difficult,  in  fact  in  certain  cases 
impossible,  to  discriminate  between  simple  cheesy  pneumonia  and 
cheesy  pneumonia  which  has  ended  in  the  formation  of  tubercles. 
The  patient  has  an  attack  of  catarrhal  pneumonia ;  but,  instead  of 
absorption  of  the  inflammatory  product,  cheesy  infiltration  occurs, 
and  the  lung  in  places  becomes  infiltrated  with  pus,  softens,  and 
breaks  down.  The  patient  presents  the  symptoms  and  physical 
signs  of  phthisis.  He  may  recover  after  a  protracted  sickness,  or 
may  die.  The  disease  may,  and  often  does,  remain  a  pneumonia ; 
but  this  is  a  condition  of  the  lungs  which  favors  the  develo]3ment 
of  tubercles,  and  in  a  certain  ]3roportion  of  cases  tubercles  do  form 
in  the  last  weeks  of  life.  Though  the  difl:erential  diagnosis  in  such 
cases  between  simple  pneumonia  and  tuberculosis  supervening  on 
pneumonia  is  impossible,  practically  the  discrimination  is  unim- 
portant, as  the  same  treatment  is  required. 

Advanced  pulmonary  tuberculosis,  except  when  it  supervenes 
upon  pneumonia,  can  in  most  instances  be  readily  diagnosticated 
by  a  careful  examination.  Still,  it  is  to  be  recollected,  as  already 
pointed  out,  that  certain  of  the  symptoms  and  physical  signs,  which 
occurring  in  the  adult  would  afford  almost  positive  proof  of  pul- 
monary tuberculosis,  in  children  not  infrequently  have  a  different 
origin. 

The  diagnosis  of  tubercles  in  the  abdominal  orgaiis  is  facilitated 
by  the  presence  of  symptoms  which  indicate  at  the  same  time 
tuberculosis  of  the  lungs.  Among  the  chief  diagnostic  signs  of 
tuberculosis  of  the  peritoneum  may  be  mentioned  meteorism  and  a 
degree  of  tenderness  on  pressure.  But  there  is  danger  of  mistaking 
the  tympanitic  state  of  the  intestines  common  in  ill-nourished  in- 
fants and  the  rachitic,  or  the  fulness  due  to  enlarged  spleen  or 
liver,  to  that  occasioned  by  peritoneal  tuberculization,  and  vice 
versa.  The  history  of  the  case,  and  a  careful  examination  of 
accompanying  sympt<>ms,  and  the  shape  and  feel  of  the  abdomen, 
usually  suffice  to  establish  tlie  diagnosis.  In  simple  gaseous  disten- 
sion of  the  abdomen  there  is  an  absence  of  the  symptoms,  general 
and  local,  which  attend  tuberculosis;  rachitis  occurs  at  an  earlier 
age  than  peritoneal  tuberculosis,  and  digital  examination,  aided  by 
percussion,  enables  us  to  diagnosticate  enlargement  of  the  liver  or 
spleen. 

Tubercular  enlargement  of  the  mesentei'ic  glands  cannot  be 
positively  diagnosticated  when  they  are  small.  When  they  have 
attained  such  a  size  that  they  can  be  felt  through  the  abdominal 
walls,  palpation  in  connection  with  the  history  and  symptoms  of  tu- 


TREATMENT.  147 

berciilosis  suffices  to  establish  the  diagnosis.  Tlie  glandular  tumors 
can  be  diagnosticated  from  other  tumors  by  the  fact  that  they  are 
tender  on  j^ressure,  and  occupy  the  umbilical  region,  while  fecal 
tumors  are  not  tender,  and  are  located  in  the  iliac  or  lumbar  region. 
Gastro-intestinal  tuberculosis  cannot  be  positively  diagnosticated. 
Protracted  diarrhoea,  or  frequent  attacks  of  diarrhoea,  not  readily 
controlled  by  medicine,  and  occurring  in  tubercular  cases,  are 
probably  associated  with  intestinal  ulceration;  but  in  only  a  certain 
proportion  of  cases  of  ulceration  are  there  also  tubercles  in  the  walls 
of  the  intestines. 

Prognosis. — Death  is  the  ordinarj^  result  of  tuberculosis  in  the 
child,  as  it  is  in  the  adult ;  but  now  and  then  one  recovers.  Hos- 
pital statistics  show  that  the  average  duration  of  the  disease  is 
from  three  to  seven  months.  Under  favorable  circumstances  it  is 
more  protracted,  even  to  two  or  three  years.  Those  succumb 
soonest  who  inherit  a  strongly-marked  tubercular  diathesis,  live  in 
damp,  dark,  and  ill-ventilated  apartments,  and  whose  diet  is  scanty 
or  of  poor  quality.  Therefore  in  the  poor  quarters  of  the  city 
tuberculosis  presents  a  worse  form  and  pursues  a  more  rapid  course 
than  among  families  in  better  circumstances. 

Favorable  prognostic  signs  are  absence  of  tubercular  diathesis, 
good  appetite  and  general  health,  with  little  emaciation,  infrequency 
of  cough,  with  respiration,  pulse,  and  temperature  nearly  normal. 
Such  symptoms  may  aiford  hope  of  recovery  with  judicious  regi- 
menal and  therapeutic  measures.  On  the  other  hand,  if  the  symp- 
toms are  grave,  death  is  inevitable,  unless  in  bronchial  phthisis,  in 
which,  even  when  there  is  considerable  urgency  of  symptoms,  the 
offending  gland  is  sometimes  eliminated  by  softening  and  ulcera- 
tion, and  the  patient  improves  temporarily,  if  he  does  not  ulti- 
mately recover.  Complete  and  permanent  recovery  is,  however, 
quite  exceptional. 

Death  in  tuberculosis  of  children  may  occur  from  exhaustion 
induced  by  the  general  disease,  or  from  the  local  efifect  of  the 
tubercles.  Thus,  in  intra-cranial  tuberculosis  it  may  result  from 
coma;  in  pulmonary  tuberculosis,  from  dyspnoea,  though  more  fre- 
quently from  exhaustion;  in  that  of  the  bronchial  glands,  from 
coma,  dyspnoea,  exhaustion,  or  even  from  hemorrhage;  in  that  of 
the  abdominal  organs,  from  peritonitis  or  protracted  diarrhoea. 

Treatment.  Proiihyladk. — Though  tuberculosis  is  so  obstinate 
and  fatal,  it  is  often  in  our  power,  if  forewarned,  to  avert  it.  A 
nursing  infant,  whose  mother  has  the  disease,  should  be  immedi- 
ately taken  from  the  breast  and  intrusted  to  a  wet-nurse.     The 


14:8  TUBERCULOSIS. 

health  of  the  mother  as  well  as  infant  requires  this.  If  the  father 
has  the  disease,  and  the  mother's  milk  is  inadequate  or  of  poor 
quality,  and  the  infant  is  under  the  age  of  six  months,  the  same 
change  should  be  made,  rather  than  supply  the  deficiency  by  arti- 
ficial feeding.  Children  who  are  weaned  should  have  plain  but 
nutritious  and  easily  digested  diet,  a  part  of  which  should  be  milk. 
If  the  predisposition  to  tuberculosis  is  strong,  a  little  alcoholic  stim- 
ulant may  be  allowed  three  or  four  times  daily  in  the  milk,  though 
with  the  risk  of  creating  an  appetite  for  it.  To  an  infant  two  or 
three  drops  of  Bourbon  whisky  may  be  given  for  each  month  of 
its  age,  and  to  children  of  three  to  five  years  a  teaspoonful.  Resi- 
dence in  an  airy  and  salubrious  locality,  out-door  exercise,  a  scru- 
pulous avoidance  of  exposure  by  which  a  cold  might  be  contracted, 
are  necessary  in  order  to  the  continued  latency  of  the  diathesis. 
Loss  of  flesh  or  appetite,  or  other  evidences  of  failing  health,  indi- 
cate the  need  of  additional  measures  of  a  therapeutic  character. 
Iron,  with  cod-liver  oil,  citrate  of  iron  and  quinine,  elixir  of  cal- 
isaya  bark,  or  other  tonic,  should  be  employed  in  connection  with 
the  alcoholic  stimulant  and  suitable  regimen.  By  the  employment 
of  such  precautionary  measures  as  soon  as  indicated,  multitudes  of 
children  might  be  saved  from  this  disease  who  now  perish. 

Curative. — The  treatment  of  the  general  disease  should  be  the 
same  in  children  as  in  adults.  The  medicinal  curative  agents 
which  are  required  in  ordinary  cases  are  cod-liver  oil,  iron,  or  other 
tonic,  and  an  alcoholic  stimulant  given  three  or  four  times  daily. 
The  oil  is  less  unpleasant  and  more  readily  taken  when  combined 
with  the  stimulant.  An  eligible  mixture  is  equal  parts  of  cod- 
liver  oil  and  wine  of  iron,  or  cod-liver  oil  with  half  its  quantity  of 
Bourbon  whisky,  and  a  few  drops  of  the  tincture  of  chloride  of 
iron.  It  sliould  be  given  after  nursing  or  the  meals.  At  the  age 
of  one  year  two  drops  of  the  tincture  of  iron  and  a  teaspoonful  of 
cod-liver  oil  would  constitute  an  ordinary  dose. 

If  the  cod-liver  oil  is  not  tolerated,  or  if  it  impairs  the  appe- 
tite, it  should  be  discontinued.  In  cases  of  diarrlioea  it  is  of  little 
or  no  benefit,  and  may  do  harm.  Under  such  circumstances  pa- 
tients sometimes  do  better  with  simple  regjimenal  measures,  aided 
by  alcoholic  stimulants,  and  one  of  the  least  unpleasant  of  the 
tonics,  as  wine  of  iron  or  the  calisaya  bark.  The  regimen  already 
recommended  for  prevention,  is  also  required  as  a  part  of  the  cura- 
tive treatment. 

Certain  modifications  of  treatment  are  demanded  on  account  of 
the  localization  of  the  tubercles.     Intra-cranial  tuberculosis,  as  soon 


SYPHILIS.  149 

as  diagnosticated,  slioiild  be  treated  by  pretty  decided  doses  of 
iodide  of  potassium,  though,  unfortunately,  there  is  little  prospect 
of  improvement.  The  glandular  disease,  whether  bronchial  or 
mesenteric,  requires  the  iodide  of  iron,  with  or  without  that  of 
potassium.  Pneumonitis-  or  pleuritis,  so  frequent  a  complication 
of  pulmonary  tuberculosis,  requires  emollient  poultices,  with  mode- 
rate counter-irritation,  and  the  judicious  use  of  opiates  with  stim- 
ulants. The  peritonitis  occurring  in  abdominal  tuberculosis,  which 
is  usually  circumscribed,  is  best  treated  by  fomentations  and  poul- 
tices, with  opiates,  and  the  diarrhoea  by  subnitrate  of  bismuth  and 
chalk,  five  to  ten  grains *of  each,  or  the  bismuth  with  Dover's 
powder;  or  a  more  active  astringent. 


CHAPTER  IV. 

SYPHILIS. 

Syphilis  in  infancy  and  childhood  presents  itself  under  two  forms, 
namely,  the  congenital  and  acquired ;  the  former  is  the  more  fre- 
quent. 

Etiology. — Congenital  syphilis  may  be  derived  from  either  father 
or  mother.  Either  parent,  having  previously  had  syphilis,  may 
transmit  it  to  the  offspring,  although  at  the  time  free  from  syphi- 
litic symptoms.  The  mother,  healthy  at  the  time  of  conception, 
but  infected  with  syphilis  prior  to  the  eighth  month  of  gestation, 
may  communicate  the  disease  to  the  foetus;  syphilis  contracted  in 
the  eighth  or  ninth  month  does  not  affect  the  fcetus.  If  both  pa- 
rents have  syphilis,  the  infant  is  almost  necessarily  syphilitic;  on 
the  other  hand,  if  only  one  parent  is  affected,  the  infant  may  or 
may  not  be  contaminated.  Sometimes,  with  such  parentage,  a 
part  of  the  children  are  syphilitic,  and  a  part  healthy. 

Acquired  syphilis  in  infancy  and  childhood  may  be  received 
through  primary  lesions — that  is,  by  reception  of  the  virus  from  a 
chancre  or  bubo ;  or  it  may  be  derived  from  certain  of  the  secondary 
lesions.  Inoculation  by  primary  lesions  may  occur  at  the  birth  of 
the  infant,  from  a  syphilitic  sore  in  the  vagina  or  upon  the  vulva 
of  the  mother;  inoculation  in  this  manner  is,  however,  rare.  Chil- 
dren may  also  receive  the  virus  from  primary  lesions  on  the  persons 
of  nurses  or  companions.     Infection  in  this  manner  is  sometimes 


150  SYPHILIS. 

accidental,  and  sometimes  the  result  of  criminal  conduct.  A  chancre 
on  the  breast  of  the  wet-nurse  not  very  infrequently  communicates 
syphilis  to  the  nursling. 

The  contagiousness  of  "  secondary  manifestations,"  for  a  long 
time  doubted,  is  now  fully  established.  S\'philis  may  be  communi- 
cated by  the  secretion  or  exudation  of  a  mucous  patch,  or  a  second- 
ary sore.  Hence  the  danger  of  lactation  by  unhealthy  wet-nurses, 
though  they  present  no  symptoms  of  recent  syphilis.  Excoriations 
or  sores  upon  the  nipple  or  breast  of  an  infected  wet-nurse  may 
communicate  the  disease  to  the  nursling;  and,  on  the  other  hand, 
mucous  tubercles  or  fissures  upon  the  lips  or  tongue  of  the  infected 
infant  may  be  the  means  of  contaminating  a  healthy  wet-nurse. 
Many  such  cases  are  now  contained  in  the  records  of  medicine. 
Vaccination  by  means  of  the  scab  is  also  a  mode  by  which  consti- 
tutional syphilis  may  be  communicated.  For  further  particulars  in 
reference  to  this  subject  the  reader  is  referred  to  our  remarks  on 
vaccination. 

Clinical  History. — Syphilis  occurring  in  the  fcetus  often  destroys 
its  life  and  produces  miscarriage.  The  foetus  has  a  shrivelled  and 
diseased  appearance,  its  skin  peels,  the  liver  is  occasionally  indu- 
rated, and  abscesses  with  spots  of  inflammation  are  sometimes  ob- 
served in  the  thymus  gland.  So  frequently  is  syphilis  a  cause  of 
non-viability,  that,  as  Trousseau  has  remarked,  this  disease  should 
be  suspected  as  the  cause  whenever  a  woman  repeatedly  aborts. 
Abortion  from  syphilis  commonly  occurs  at  or  about  the  sixth 
month  of  gestation. 

The  viable  infant,  affected  with  syphilis,  ordinarily  presents,  at 
birth,  no  symptoms  or  appearances  which  indicate  the  nature  of  the 
disease  with  which  it  is  contaminated.  But  there  are  exceptions. 
Recently  I  was  enabled  to  diagnosticate  syphilis  in  an  infant  within 
a  day  after  birth,  by  its  small  size  and  feebleness,  and  the  appear- 
ance of  large  blebs  of  pemphigus  upon  the  hands  and  feet,  fingers 
and  toes,  over  which  the  skin  soon  broke,  leaving  troublesome  and 
bleeding  sores;  coryza  commenced  about  the  twelfth  day.  The 
parents  of  this  child  appeared  healthy,  but  I  could  finally  trace  the 
syphilitic  taint  to  the  mother.  Well-marked  pemphigvis  in  the 
new-born  may  be  considered  pathognomonic  of  syphilis.  Bouchut 
saw  a  seven  and  a  half  months'  infant  born  alive  with  an  erup- 
tion of  a  copper-color  upon  the  legs  and  arms,  and  onyxis  upon  the 
fingers  and  toes.  Condylomata,  mucous  patches,  and  stains  of  a 
copper-color  are  the  principal  syphilitic  afi:ections,  besides  pem- 
phigus, which  have  been  observed  at  birth  on  the  bodies  of  con- 


CLINICAL    HISTORY.  151 

taniinated  infants.  It  is  stated  that  M.  CuUerier,  in  ten  years' 
attendance  at  the  Hopital  de  Louraine,  met  only  two  cases  of  syphi- 
litic manifestations  at  birth,  and  Victor  de  Meric  only  two  cases 
in  forty-six  infants,  who  were  affected  with  congenital  syphilis 
(Bumstead) ;  but  in  the  practice  of  others  a  larger  proportion  have 
exhibited  symptoms  at  birth.  Ordinarily  the  period  in  which 
congenital  syphilis  is  first  revealed  by  symptoms  is  between  the 
fifteenth  and  fortieth  days.  Rarely  the  manifestation  of  the  dis- 
ease is  delayed  several  months.  M.  Diday  ascertained  the  time  of 
the  commencement  of  symptoms  in  158  cases,  as  follows: — 

Before  the  completion  of  one  month  after  birth,  in     ...  86 

"  "         two  months        "                  ...  45 

"  "         three    "              "                  ...  15 

At  four  months 7 

"   five       " 1 

"  six        " 1 

"   eight    " 1 

"   one  year 1 

"   two  years 1 

In  cases  of  tardy  commencement  of  syphilitic  symptoms  it  is 
probable  that  the  disease  has  been  partially  eradicated  from  the 
afiected  parent  by  appropriate  treatment. 

The  nutrition  of  the  infant  who  has  inherited  the  syphilitic 
taint,  but  does  not  exhibit  it  at  birth,  is  for  a  time  good,  but  it 
begins  to  be  impaired  when  the  local  manifestations  of  syphilis 
appear,  or  soon  after.  The  system  gradually  wastes ;  the  skin  loses 
its  fresh  and  healthy  appearance,  and  becomes  sallow,  and,  after  a 
time,  more  or  less  wrinkled;  the  features  become  pinched  or  con- 
tracted, and  wear  a  sad  expression.  M.  Diday  says :  "  Next  to  this 
look  of  little  old  men,  so  common  in  new-born  children  doomed  to 
syphilis,  the  most  characteristic  sign  is  the  color  of  the  skin." 
Trousseau  thus  describes  this  discoloration  of  the  surface:  "  Before 
the  health  becomes  afiected,  the  child  has  already  a  peculiar  appear- 
ance ;  the  skin,  especially  that  of  the  face,  loses  its  transparency ; 
it  becomes  dull,  even  when  there  is  neither  pufliness  nor  emacia- 
tion ;  its  rosy  color  disappears,  and  is  replaced  by  a  sooty  tint, 
which  resembles  that  of  Asiatics.  It  is  yellow  or  like  coffee  mixed 
with  milk,  or  looks  as  if  it  had  been  exposed  to  smoke ;  it  has  an 
empyreumatic  color,  similar  to  that  which  exists  on  the  fingers  of 
persons  who  are  in  the  habit  of  smoking  cigarettes.  It  appears  as 
if  a  layer  of  coloring  had  been  laid  on  unequally;  it  sometimes 
occupies  the  whole  of  the  skin,  l)ut  is  more  marked  in  certain 
favorite  spots,  as  the  foreliead,  eyebrows,  chin,  nose,  eyelids — in 


152  SYPHILIS. 

short,  the  most  prominent  parts  of  tlie  face ;  the  deeper  parts,  such 
as  the  internal  angle  of  the  orbit,  the  hollow  of  the  cheek,  and  that 
which  separates  the  lower  lip  from  the  chin,  almost  always  remain 
free  from  it.  Although  the  face  is  commonly  the  part  most  atiected, 
the  rest  of  the  body  always  participates  more  or  less  in  this  tint. 
The  child  becomes  pale  and  wan." 

The  infant  whose  system  is  profoundly  affected  by  syphilis 
rarely  smiles,  and  its  voice  is  feeble  and  plaintive ;  its  fre(,iuent 
whimpering  cry  is  quite  characteristic. 

CoRYZA  is  one  of  the  earliest  and  most  constant  of  the  local  affec- 
tions which  occur  in  infantile  syphilis.  It  is  slight  at  first,  attracting 
little  attention  from  the  parents,  who  are  not  aware  of  its  signifi- 
cance, and  usually  attribute  it  to  a  slight  cold ;  but  it  gradually 
increases.  It  gives  rise  to  a  secretion  from  the  Schneiderian  mem- 
brane, at  first  thin,  but  which  becomes  more  consistent,  and  is 
attended  bv  the  formation  of  scabs.  The  thickening  of  the  mucous 
membrane  in  consequence  of  the  inflammation  and  the  presence  of 
crusts  narrows  the  passage  through  the  nostrils  so  as  to  produce 
snufiling  respiration,  and  sometimes  render  nursing  ditficult.  In 
severe  cases  respiration  through  the  nostrils  is  almost  wholly  pre- 
vented, so  that  death  may  occur  from  inanition,  unless  the  breast 
is  milked  into  the  intant's  mouth  or  it  is  fed  with  a  spoon  ;  but 
ordinarily,  eyen  in  o-rave  corvza,  it  continues  to  nurse,  thou2;h 
obliged  often  to  release  its  hold  of  the  nipple  to  obtain  breath.  It 
is  when  coryza  begins  to  interfere  with  lactation  that  it  first  alarms 
the  parents.  The  inflammation  at  the  same  time  may  aflect  the 
throat  and  larvnx,  causinsr  hoarseness  of  the  voice.  Ulceration  of 
the  Schneiderian  membrane  and  the  subjacent  cartilage  or  bone  is 
rare  in  infancy  or  childhood,  although  cases  occur  which  are  even 
attended  with  more  or  less  flattening  of  the  nose.  Diday  believes 
that  the  discharge  which  accompanies  coryza  is  in  great  part  due 
to  mucous  patches  developed  on  the  Schneiderian  membrane.  The 
upper  lip,  over  which  the  discharge  flows,  becomes  red,  excoriated, 
and  more  or  less  incrusted.  The  coryza,  in  most  cases,  coexists 
with  other  local  syphilitic  attections.  Occasionally  it  occui-s  alone, 
and  is  the  only  evidence  of  the  presence  of  the  specific  taint,  except 
such  as  is  attbrded  by  the  mal-nutrition  and  general  appearance  of 
the  patient. 

Mucous  PATCHES  occur  in  most  patients.  They  are  developed  either 
upon  the  mucous  surfaces,  or  upon  parts  of  the  skin  which  are 
thin  and  exposed  to  friction,  and  such  as  are  moistened  by  secretion 
or  transudation  from  the  vessels  underneath.     The  most  common 


ACNE,    IMPETIGO,    AND    ECTHYMA.  153 

seat  of  mucous  jtatches  is  at  the  termination  of  mucous  canals ; 
but  in  infancy,  on  account  of  the  peculiar  delicacy  of  the  skin, 
they  may  occur  upon  almost  any  part  of  the  cutaneous  surface. 
They  are  most  common,  however,  around  the  anus,  upon  the  vulva, 
scrotum,  umbilicus,  laljial  commissures,  in  the  axillae,  and  behind 
the  ears. 

Mucous  patches  upon  the  skin  present  a  rounded  border,  and 
are  slightly  elevated.  Their  color  has  been  compared  to  that  of 
the  skin  which  has  been  softened  by  the  prolonged  application  of 
a  poultice.  Erosions  and  cracks  sometimes  occur  in  the  patches, 
from  which  a  thin  liquid  exudes. 

Upon  mucous  surfaces  they  are  less  elevated  than  upon  the  skin, 
and  are  prone  to  ulcerate.  These  ulcerations,  commencing  at  the 
centre,  extend,  and  soon  the  mucous  patch  disappears,  and  its  site 
is  occupied  by  an  ulcer.  The  ulcer  may  be  circular,  oval,  elliptical, 
crescentic,  or  irregular.  The  arches  of  the  fauces  are  a  common  seat 
of  mucous  patches. 

Roseola  is  an  occasional  symptom  of  infantile  syphilis.  "It  is 
distinguished,"  says  Diday,  "  by  patches  of  a  bright  rose-color,  cir- 
cumscribed, irregularly  rounded,  of  various  sizes  (most  frequently 
about  as  large  as  one  of  the  nails);  appearing,  by  preference,  on 
the  belly,  lower  part  of  the  chest,  neck,  and  inner  surface  of  the 
extremities."  The  spots  do  not  readily  and  fully  disappear  by  pres- 
sure. 

Pemphigus  appearing  soon  after  birth  has  already  been  alluded 
to.  Its  most  frequent  seat,  whether  occurring  after  birth  or  as  a 
subsequent  manifestation,  is  the  palms  of  the  hands,  soles  of  the 
feet,  the  fingers,  and  toes.  This  eruption  commences  by  a  violet 
tint  of  the  skin,  and  in  the  course  of  twenty-four  to  forty  eight 
hours  a  watery  fluid  collects  underneath,  which  soon  becomes 
turbid.  The  skin  peels  oft',  and  sometimes  an  angry  sore  results,* 
which  bleeds  readily  when  rubbed  or  pressed.  In  other  and  more 
favorable  cases  new  skin  takes  the  place  of  that  which  is  lost. 
Pemphigus  at  birth  is  a  precursor  of  death,  but  when  it  appears 
for  the  first  time  some  weeks  after  birth,  it  is  a  less  unfavorable 
prognostic.  In  cases  of  recovery  it  disappears,  with  projjer  treat- 
ment, in  two  or  three  weeks. 

Acne,  impetigo,  and  ecthyma  are  occasionally  observed  in  children 
afflicted  with  syphilis.  The  indurated  pustules  of  acne  occur  most 
frequently  upon  the  shoulders,  back,  chest,  and  buttocks.  The 
pus  is  sometimes  absorbed,  and  in  other  cases  discharged,  leaving  a 
small  cicatrix,  which,  after  a  time,  disappears.     Impetigo  appears 


154:  SYPHILIS. 

most  frequently  upon  the  face,  and  occasionally  upon  the  chest, 
neck,  axilla,  and  groins.  Unlike  simple  impetigo,  the  sj-philitic 
impetiginous  eruption  is  surrounded  by  a  copper-colored  areola. 
Ecthyma  occurs  upon  the  legs  and  buttocks  chiefly.  It  com- 
mences as  violet-colored  spots,  which  are  soon  transformed  into 
pustules.  Ulcers  succeed,  which,  in  reduced  states  of  the  system, 
are  apt  to  enlarge,  and  endanger  the  safety  of  the  child.  Of  the 
three  pustular  eruptions,  acne,  according  to  Diday,  is  the  least 
serious — indicating  a  "  less  confirmed  diathesis."  Ecthyma  is  the 
most  serious,  on  account  of  the  reduced  state  of  system  with 
which  it  is  apt  to  be  associated.  Syphilitic  papulpe  and  squam?e 
are  rare  in  infants,  but  cases  have  been  observed.  Onychia  occa- 
sionally occurs,  though  less  frequently  than  in  syphilis  of  the 
adult. 

Visceral  Lesions. — The  visceral  lesions  which  occur  in  the 
syphilis  of  infancy  and  childhood  are,  suppuration  in  the  thymus 
gland ;  gummy  tumors  in  certain  organs,  most  frequently  the  lungs 
and  liver;  increase  of  the  connective  tissue  of  the  liver,  known  as 
syphilitic  cirrhosis;  partial  perihepatitis,  with  depressions  resem- 
l)ling  cicatrices  on  the  surface  of  the  liver;  peritonitis;  periostitis, 
with  thickening  of  the  bone  and  exostosis. 

Suppurative  inflammation  in  the  thymus  gland  is  not  common, 
or  has  not  been  frequently  observed.  "When  it  is  present,  the 
gland  sometimes  presents  its  normal  appearance  externally,  and 
the  abscess  is  only  discovered  by  incisions.  Gummy  tumors  are 
white  and  spheroidal ;  some  are  as  small  or  smaller  than  a  pin's 
head,  while  others  are  as  large  as  a  pea,  or  even  a  hazel-nut.  I 
have  seen  a  considerable  number  of  them  not  as  large  as  a  pin's 
head,  in  the  liver  of  an  infant.  Gummy  tumors,  according  to 
Lebert,  consist  "of  loose  fibrous  tissue,  made  up  of  pale  elastic 
.  fibres,  inclosing  in  their  large  interspaces  a  homogeneous  granu- 
lar substance,  the  elements  of  which  are  less  adherent  to  each 
other  than  in  deposits  of  true  tubercle."  Lebert  also,  with  other 
microscopists,  discovered  round  granular  cells  in  these  tumors. 
According  to  Robin,  gummy  tumors  "are  made  up  of  rounded 
nuclei  belonging  to  fibro-plastic  cells,  or  cytoblastions ;  of  a  finely 
granular,  semi-transparent  and  amorphous  substance ;  and,  finally, 
of  isolated  fibres  of  cellular  tissue,  a  small  number  of  elastic  fibres, 
and  a  few  capillary  bloodvessels." 

Constitutional  sj-philis  is  one  of  the  principal  causes  of  waxy 
degeneration,  and  the  spleen  and  liver  of  infants  may  be  enlarged 
from  this  cause.    Dr.  Samuel  Gee  has  expressed  the  opinion  that  in 


VISCERAL    LESIONS.  155 

half  the  cases  of  hereditary  syphilis  the  spleen  is  enlarged.  (Lond, 
Lancet,  April  13,  1867.) 

Infiltration  of  the  liver  by  fibrous  substance  was  first  noticed 
by  Giibler.  It  is  not  common  in  the  infant.  A  specimen,  showing 
this  lesion,  was  presented  to  the  London  Pathological  Society  in 
1866,  by  Dr.  Samuel  Wilks.  The  following  remarks  by  Dr.  Wilks 
convey  a  good  idea  of  the  appearance  and  state  of  the  liver  in 
syphilitic  cirrhosis:  "Having  dissected  the  bodies  of  several  in- 
fants, who  have  died  of  congenital  syphilis,  I  have  found  fetty 
livers,  and  an  inflammation  of  the  capsule ;  but  in  only  two  have  I 
discovered  adventitious  products  of  a  fibrous  character.  The  pre- 
sent example,  however,  corresponds  in  every  particular  with  the 
disease  described  by  Giibler.  It  must  be  distinguislied  (at  least 
as  far  as  the  naked  eye  appearance  reaches)  from  the  syphilitic 
disease  of  adults,  of  which  many  specimens  have  been  before  the 
Society.  In  these  the  organ  is  cicatrized  on  the  surface,  and  con- 
tains distinct  nodules  of  fibrous  tissue;  whilst  in  the  disease  of 
children,  as  in  the  present  specimen,  the  whole  organ  is  infiltrated 
by  a  new  material,  and  it  consequently  becomes,  as  described  by 
Giibler,  hypertrophied,  globular,  and  hard,  resistant  to  pressure, 
and  even  when  torn  by  the  fingers,  its  surface  receives  no  indenta- 
tion from  them ;  it  is  also  elastic,  and  when  cut  creaks  slightly  under 
the  scalpel.  This  was  the  form  of  disease  in  the  present  specimen. 
It  came  from  a  syphilitic  child,  a  month  old,  in  whom  the  liver 
could  be  felt  enlarged  during  life,  and  when  removed  weighed  a 
pound  and  a  half.  It  was  smooth  on  the  surface,  and  so  hard  that  it 
resembled  rather  a  fibrous  tumor  than  a  liver."  It  is  seen  that  the 
liver  in  the  syphilitic  child  is  liable  to  three  distinct  pathological 
processes,  namely,  gummy  tumors,  cirrhosis  or  fibroid  degeneration, 
and  waxy  degeneration. 

Syphilitic  perihepatitis  and  periostitis  are  more  rare  in  infanc}'- 
and  childhood  than  in  adult  life,  but  they  occasionally  occur.  Prof. 
Simpson,  of  Edinburgh,  considers  peritonitis  in  the  foetus  one  of 
the  results  of  syphilis,  and  the  cause  of  its  death. 

Mr.  Hutchinson,  of  London,  has  called  the  attention  of  the  pro- 
fession to  certain  observations  of  his,  which,  if  corroborated,  are 
important.  According  to  him,  hereditary  syphilis  becoming  latent, 
sometimes  manifests  itself  again  after  the  age  of  five  years,  by 
another  set  of  symptoms.  One  of  these  manifestations  is  a  dwarf- 
ing of  the  incisor  teeth,  which  are  rounded  and  peg-like,  with 
notched  edges.  On  account  of  the  shape  and  small  size  of  the  teeth, 
there  are  interspaces  between  them.     This  malformation  is  most 


156  SYPHILIS. 

marked  in  the  central  incisors  of  the  upper  jaw,  and  in  dertain 
cases  it  is  limited  to  them,  and  it  never  appears  in  the  other  in- 
cisors unless  it  does  also  in  them.  Another  symptom,  which  only 
appears  in  hereditary  syphilis,  is  an  interstitial  keratitis  occur- 
ring on  both  sides,  and  attended  by  the  deposition  of  fibrin  in  the 
substance  of  the  cornea.  In  a  few  weeks  the  inflammation  de- 
clines, but  a  slight  opacity  of  the  cornea  remains.  The  cerebral 
nerves  may  become  affected,  usually  a  single  pair — if  the  audi- 
tory, deafness  resulting;  if  the  optic,  dimness  of  sight.  Occasion- 
ally there  are  other  manifestations  of  syphilis  in  this  period,  as 
enlargement  of  spleen  and  liver,  and  nodes  upon  the  long  bones. 

Prognosis. — This  depends  in  great  part  on  the  general  condition 
of  the  patient.  If  there  is  much  emaciation,  and  the  symptoms 
indicate  a  deeply-seated  cachexia,  a  considerable  proportion  perish. 
On  the  other  hand,  if  the  general  health  is  not  greatly  impaired, 
although  the  local  affections  are  pretty  severe,  the  prognosis  with 
correct  treatment  is  good.  The  younger  the  infant,  when  the 
symjjtoms  of  syphilis  appear,  the  more  unfavorable,  as  a  rule,  is  the 
prognosis. 

Treatjiext. — Parents  who  beget  syphilitic  children  ought,  from 
a  due  regard  for  their  offspring,  to  make  use  of  anti-syphilitic  reme- 
dies, although  they  present  in  their  persons  no  evidences  of  syphi- 
litic taint.  A  good  prescription  for  the  parents  is  one-sixteenth  of 
a  grain  of  corrosive  sublimate  in  the  compound  tincture  of  bark, 
given  twice  or  three  times  dailj'  for  several  weeks.  If  the  father 
has  had  syphilis,  both  parents  should  be  subjected  to  this  treat- 
ment, and  it  may  be  continued,  at  least  on  the  part  of  the  mother, 
during  the  first  months  of  her  gestation.  So  small  a  dose  of  the 
mercurial  does  not,  in  my  opinion,  materially  increase  the  liability 
to  miscarry.  There  is  much  more  danger  of  miscarrying  from 
allowing  the  syphilitic  taint  to  remain  uncontrolled.  Some  prefer 
the  use  of  mercurial  ointment  in  the  treatment  of  pregnant  women 
for  syphilis,  in  the  belief  that  it  is  less  likely  to  produce  abortion. 
It  is  used  for  this  purpose  in  the  proportion  of  one  drachm  to  the 
ounce.  It  is  equally  eftectual  in  the  eradication  of  the  syphilitic 
taint  with  the  small  dose  of  corrosive  sublimate,  recommended 
above  for  internal  administration;  but  it  is  impossible  to  deter- 
mine the  quantity  of  mercury  which  enters  the  circulation  when 
inunction  is  employed,  and  salivation  is  more  likely  to  occur. 

Syphilis  in  the  infant  requires  mercurial  treatment  as  in  the 
adult.  Mercury  may  be  employed  internally  or  by  inunction. 
Some  prefer  inunction  in  the  treatment  of  ordinary  cases,  in  the 


TREATMENT.  157 

manner  recommended  by  Sir  Benjamin  Brodie.  "I  liave  spread,"' 
says  he,  "mercurial  ointment,  made  in  the  proportion  of  a  drachm 
to  an  ounce,  over  a  flannel  roller,  and  bound  it  round  the  child, 
once  a  day.  The  child  kicks  about,  and,  the  cuticle  being  thin, 
the  mercury  is  absorbed.  It  does  not  either  gripe  or  purge,  nor 
does  it  make  the  gums  sore,  but  it  cures  the  disease.  I  have 
adopted  this  practice  in  a  great  many  cases,  with  the  most  signal 
success."  Trousseau,  on  the  other  hand,  discountenances  the  use 
of  inunction,  as  mercurial  ointment  applied  to  the  skin  produces 
irritation,  and  increases  the  suifering  and  restlessness  of  the  child. 
He  prefers  the  following  solution,  which  is  known  as  Yan  Swie- 
ten's,  for  internal  treatment: — 

R.  Hydrarg.  bichlorid.  1  part; 
Aquae  900  parts; 
Spts.  rectific.  100  parts.     Misce. 
Dose,  one,  or  at  most,  two  grammes  (23  to  46  gr.)  in  milk,  daily. 

As  regards  the  choice  between  inunction  and  internal  treatment, 
it  may  be  said  that  the  former  is  preferable  in  very  reduced  states 
of  system,  and  in  those  who  are  affected  with  diarrhoea.  The 
ointment  should  not  be  applied  to  much  of  the  surface;  two  or 
three  square  inches  are  sufficient.  To  avoid  inflaming  the  surface, 
the  position  of  it  may  be  varied  from  time  to  time,  and  it  need  not 
be  continuously  applied.  In  cases  other  than  those  excepted  above, 
I  prefer  internal  treatment.  Yan  Swieten's  liquid  may  be  given, 
or  one  of  the  following  formulae  may  be  employed : — 

R.  Hydrarg.  cum  creta  gr.  iij-vj; 
Sacch.  alb.  9j.     Misce. 
Divid.  in  chart.  No.  xii.     One  powder  3  times  dail3^ 

R.  Hydrarg.  chlor.  corros.  gr.  i-ij  ; 
Syr.  sarsse  comp.  gij  ; 
Aquae  5viij.     Misce. 
One  teaspoonful  3  times  daily. 

Mercury,  in  whatever  way  employed,  should  not  be  discontinued 
entirely  till  several  weeks  after  the  syphilitic  symptoms  have  dis- 
appeared ;  it  is  proper  to  continue  it  for  a  time,  in  diminished 
quantity,  after  the  health  seems  fully  restored. 

When  the  mercurial  is  omitted,  tonics  are  often  required.  The 
preparations  of  cinchona  are  useful  in  certain  cases,  as  are  also 
those  of  iron.  If  the  patient  remain  feeble  and  pallid,  present- 
ing evidences  of  struma,  cod-liver  oil  and  syrup  of  the  iodide 
of  iron  will  be  found  beneficial  continued  for  some  weeks  or  months 
after  the  mercurial  is  discontinued.     Attention  should  always  be 


158  SYPHILIS. 

given  to  cleanliness  and  the  hygienic  management  of  the  child. 
In  some  instances  direct  treatment  of  the  local  afl'ections  is  service- 
able. Injections  of  a  solution  of  chlorate  of  potash  into  the  nos- 
trils have  a  good  eifect  in  syphilitic  coryza,  and  the  application  to 
the  inflamed  surface  daily  of  citrine  or  white  precipitate  ointment 
diluted  with  an  equal  amount  of  lard.  Condylomata  or  mucous 
patches  sealed  upon  the  cutaneous  surface  may  be  dusted  with  calo- 
mel. At  my  clinique  in  April,  1871,  a  child  two  years  and  ten 
months  old  was  presented,  with  a  large  condylomatous  outgrowth 
near  the  anus.  The  history  of  the  child  showed  that  in  all  proba- 
bility the  disease  had  been  contracted  within  a  year  from  syphilitic 
cliildren  in  one  of  the  public  institutions.  Within  three  weeks  this 
afteetion  nearly  disappeared  by  dusting  upon  it  calomel  daily,  with 
appropriate  internal  treatment. 


sectio:n"  II. 

ERUPTIVE  FEVERS. 


CHAPTER  I. 

MEASLES. 


The  disease  known  in  the  vernacular  as  measles  lias  also  the 
names  rubeola  and  morbilli.  It  is  a  common  exanthematic  aiFec- 
tion,  occurring  at  any  age,  but  most  frequently  in  childhood.  It 
affects  once  the  majority  of  mankind.  Writers  recognize  three 
stages  of  measles:  first,  that  of  invasion,  which  ends  with  the 
appearance  of  the  eruption;  secondly,  the  eruptive  stage;  and 
thirdly,  the  stage  of  decline  or  desquamation. 

Symptoms. — This  disease  commences  with  such  symptoms  as  usu- 
ally occur  in  mild  but  pretty  general  inflammation  of  the  air-pas- 
sages, namely,  cough,  fever,  anorexia,  and  thirst.  The  eyes  present 
a  suffused,  moderately  injected,  and  brilliant  appearance,  and  the 
buccal  and  faucial  surface  is  injected.  The  Schneiderian  mem- 
brane, and  that  lining  the  larjaix,  trachea,  and  bronchial  tubes, 
participate  in  the  increased  vascularity.  The  cough  at  first  is  dry, 
and  sometimes  distinctly  croupy.  Catarrhal  or  false  croup,  indeed, 
is  not  infrequent  in  the  initial  period  of  measles.  The  cough  is 
attended  by  little  acceleration  of  respiration,  and  by  little  or  no 
pain  in  the  respiratory  movements.  If  auscultation  is  practised  at 
this  early  stage,  we  observe  the  vesicular  murmur,  somewhat  harsh 
in  character,  and  sometimes  sonorous  and  sibilant  rales.  A  little 
later,  rales  of  a  moist  character  appear. 

The  patient,  if  old  enough,  commonly  complains  of  headache, 
and  of  dull  pain  in  the  epigastric  region  or  the  centre  of  the  ster- 
num, due  to  the  bronchitis.  With  these  local  symptoms  febrile 
reaction  occurs.  The  temperature  rises  to  about  102°  or  103°,  as 
indicated  by  the  thermometer  in  the  axilla.  The  pulse  numbers 
from  110  to  130  per  minute.     The  fever  is  somewhat  greater  than 


160  MEASLES. 

ill  primary  traclieo-bronchitis,  except  when  the  bronchitis  becomes 
capillary,  but  it  is  less  than  in  most  cases  of  scarlet  fever. 

The  fever  in  the  premonitory  stage  of  measles  after  the  first  day 
is  not  uniform.  It  is  attended  by  remissions  and  exacerbations, 
the  former  occurring  in  the  first  part  of  the  day,  the  latter  in  the 
evening.  Sometimes  two  exacerbations  occur  in  the  day.  The 
face  is  flushed  and  somewhat  swollen,  especially  during  the  times 
of  increase  in  the  fever,  and  the  child  is  drowsy  or  restless.  Vom- 
iting, so  common  a  symptom  in  the  commencement  of  scarlet  fever, 
occasionally  occurs  in  measles.  While  in  scarlet  fever  this  takes 
place  in  the  first  twenty-four  hours,  in  measles  it  occurs  with  about 
equal  frequency  at  any  period  previously  to  the  eruption.  It  was 
present  during  the  first  stage,  sometimes  almost  as  late  as  the  erup- 
tive period,  in  thirteen,  and  was  absent  in  twenty-three  cases,  of 
which  I  have  preserved  records. 

The  duration  of  the  first  stage  varies  in  different  cases.  It  is 
usually  from  two  to  five  days,  with  an  average  of  about  four.  Oc- 
casionally it  is  more  protracted  on  account  of  some  disturbance  in 
the  economy,  either  from  exposure  to  cold  or  other  cause,  which 
prevents  the  necessary  afflux  of  blood  towards  the  surface,  and  re- 
tards the  eruption.  In  eighteen  cases  in  my  practice  in  which  the 
duration  of  the  cough  previously  to  the  appearance  of  rash  was 
accurately  ascertained,  the  time  varied  from  one  to  five  days,  with 
an  average  of  three  and  one-third;  in  ten  other  cases  it  had  con- 
tinued, the  parents  stated,  about  a  week,  and  in  five,  from  one  to 
two  weeks,  previously  to  the  eruption. 

The  eruption  commences,  when  the  disease  pursues  its  normal 
course,  upon  the  forehead  and  neck,  then  the  face,  and  gradually 
extends  downwards,  occupying  from  twenty-four  to  thirty-six 
hours  in  passing  over  the  trunk  and  limbs.  It  appears  first  as 
indistinct  red  points  not  more  than  a  line  in  diameter,  which  in- 
crease in  size  and  become  more  distinct.  Their  borders  are  uneven 
or  irregular,  or  they  are  finely  notched ;  their  general  shape  is,  how- 
ever, circular,  except  as  two  or  more  unite,  when  they  may  assume 
any  form.  The  crescentic  form  which  writers  describe  is  due  to  the 
union  of  two  jDoints  of  eruption.  The  largest  of  these  spots,  when 
there  is  no  coalescence,  do  not  exceed  a  quarter  of  an  inch  in  diam- 
eter, and  many  are  much  smaller.  Frequently  in  plethoric  chil- 
dren, if  there  is  much  fever,  there  is  continuous  redness  over  seve- 
ral inches  of  surface.  The  eruption  is  then  confluent.  This  form  is 
often  observed  upon  parts  of  the  surface  where  the  capillary  circu- 
lation is  most  active,  when  it  is  discrete  elsewhere.     In  some  of 


SYMPTOMS.  IGl 

these  cases,  diagnosis  of  measles  from  scarlet  fever  is  attended  with 
difficulty. 

The  rubeolons  eruption  is  slightly  elevated.  This  is  not  appre- 
ciable to  the  sight,  but  can  be  ascertained  by  passing  the  finger 
slowly  over  the  skin,  when  a  little  roughness  is  felt  at  the  point  of 
eruption.  Sometimes  the  elevation,  especially  in  the  connnence- 
ment  of  the  eruption,  is  not  appreciable,  even  to  the  touch.  The 
eruption  is  broad  and  flat,  never  acuminate,  never  changing  its  form 
to  the  vesicular  or  pustular.  It  disappears  by  pressure,  and  imme- 
diately reappears  when  the  pressure  is  removed.  It  has  been  com- 
pared in  appearance  to  flea-bites.  Small,  pointed,  papular,  vesicular, 
or  pustular  eruptions  are  sometimes  seen  in  connection  with  those 
of  measles,  but  they  are  accidental,  occurring  in  other  states  of  sys- 
tem as  well  as  in  measles,  if  there  is  the  same  augmented  tempera- 
ture. 

In  the  commencement  of  the  eruptive  period,  the  severity  of  the 
constitutional  and  local  symptoms  increases.  The  pulse  and  tem- 
perature correspond  with  the  character  which  they  presented  during 
the  exacerbations  of  the  first  stage.  The  features  are  slightly 
swollen;  the  eyes  still  watery  and  sensitive  to  light;  the  conjnnc- 
tiva,  ocular  and  palpebral,  and  the  mucous  membrane  of  the  cavity 
of  the  mouth  and  of  the  air-passages,  continue  injected.  The 
tongue  is  covered  with  a  moist  thin  fur,  and  its  papillae  are  promi- 
nent, though  less  so  than  in  scarlet  fever.  The  cough  continues 
frequent,  and  is  seldom  attended  with  much  expectoration,  in  un- 
complicated cases ;  often  there  is  no  expectoration  whatever.  The 
appetite  is  lost,  but  drinks  are  readily  taken  on  account  of  the 
thirst.  Diarrhoea  sometimes  occurs  on  the  first  day  of  the  eruption, 
but  it  lasts  only  a  few  hours,  and,  if  the  disease  pursues  its  usual 
course,  abates  of  itself.  With  the  exception  of  this,  the  bowels 
are  regular,  or  a  little  constipated  during  the  eruptive  period. 

On  the  second  day  of  the  eruption,  or  sixth  of  the  fever,  the 
symptoms  begin  to  abate.  The  pulse  is  less  accelerated,  and  the 
temperature  diminishes ;  the  cough  is  less  frequent  and  is  easier, 
and  the  flushed  and  swollen  appearance  of  the  face  declines.  By 
the  close  of  the  third  or  on  the  fourth  day,  the  rash  has  disappeared 
in  the  order  in  which  it  extended  over  the  hody.  There  only  re- 
main faint  maculse,  which  in  the  course  of  a  day  or  two  fade 
completely. 

"With  the  disappearance  of  the  rash,  the  fever  nearly  or  quite 
ceases,  but  a  slight  and  painless  cough  continues  for  several  days. 

Occasionally  the  eruption  presents  a  livid  appearance  ;   this  is 
11 


162  MEASLES. 

the  rubeola  nigra  of  writers.  From  cases  which  I  have  observed, 
it  is  my  opinion  that  this  should  not  be  considered  a  distinct  species 
in  the  vast  majority  of  cases,  but  that  the  dark  color  is  due  to  in- 
ternal inflammation,  usually  capillary  bronchitis  or  pneumonia, 
which  prevents  full  oxygenation  of  the  blood.  Rarely  rubeola 
nigra  is  due  to  the  vitiated  state  of  the  blood,  or  the  malignant 
nature  of  the  disease.  The  course  of  the  eruption  in  this  form  of 
measles  is  somewhat  different ;  it  continues  longer,  fades  more 
slowly,  and  does  not  disappear  so  readily  on  pressure.  Traces  of 
it  are  observed  a  week  or  more  after  its  first  appearance ;  it  is  apt 
to  be  fatal.  Measles  may  present  this  form  from  the  beginning,  or 
commencing  as  vulgaris,  it  may  pass  into  rubeola  nigra. 

Measles  may  be  irregular  in  form,  but  aberrations  are  less  fre- 
quent than  in  scarlet  fever.  "Writers  describe  measles  without 
catarrh,  and,  on  the  other  hand,  measles  without  the  eruption. 
But  positive  diagnosis  in  such  cases  must  be  difficult.  It  is  pro- 
bable that  simple  catarrh  and  roseola  have  sometimes  been  mis- 
taken for  the  two  forms  of  irregularity  mentioned.  But  when  a 
child,  in  a  family  of  children  aflected  with  measles,  presents  all 
the  symptoms  of  that  disease,  except  the  catarrh  or  except  the 
eruption,  the  diagnosis  of  irregular  measles  would,  as  a  rule,  be 
correct. 

Occasionally  the  stage  of  invasion  is  very  short,  or  even  absent. 
In  one  case  the  parents  informed  me  that  the  catarrhal  symptoms 
began  on  the  day  when  the  eruption  appeared.  Convulsions  some- 
times occur  at  the  commencement  of  measles,  as  well  as  during  its 
progress.  A  single  convulsive  attack  at  the  commencement  of 
measles  is  usually  not  dangerous ;  when  repeated,  it  is  more  serious; 
it  is  also  more  serious  when  it  occurs  in  the  course  of  measles. 
In  certain  cases  the  eruption  appears  in  an  irregular  and  partial 
manner,  occurring,  perhaps,  at  a  late  period,  and  indistinctly 
upon  the  trunk  alone,  or  upon  the  trunk  and  partially  upon  the 
legs.  In  many  cases  of  deferred  or  partial  eruption  there  is  internal 
congestion  or  inflammation  of  some  part,  which  causes  withdrawal 
of  blood  from  the  surface,  and  thus  prevents  the  normal  develop- 
ment of  the  rash. 

When  the  eruption  disappears,  the  third  stage  commences,  that 
of  desquamation.  It  is  characterized  by  a  scanty  furfuraceous 
exfoliation  of  the  epidermis.  The  desquamation  is  seldom  as  great 
as  in  scarlet  fever,  and  it  occurs  most  where  the  eruption  has  been 
thickest  and  the  epidermis  most  inflamed.  Exfoliation  occui*s 
between  the  fourth  and  seventh  days  after  the  commencement  of 


COMPLICATIONS.  163 

the  eruption,  the  eighth  and  eleventh  of  the  disease.     In  some 
chiklren  it  does  not  take  place,  or  is  so  slight,  as  not  to  be  observed. 

With  the  disappearance  of  the  rash,  the  symptoms  rapidly  abate. 
The  pulse  becomes  more  natural,  the  temperature  is  reduced,  the 
digestive  organs  return  to  their  normal  state,  and  convalescence 
is  established.  The  cough  continues  several  days  after  the  other 
symptoms  abate,  but  it  is  less  and  less  frequent,  and  is  not  painful. 

Complications. — The  complications  of  this  disease  are  important. 
Much  of  the  success  of  the  physician  in  the  management  of  measles 
depends  on  a  correct  diagnosis  and  understanding  of  them.  The 
most  frequent  of  these  complications  are  bronchitis  and  broncho- 
pneumonia. Slight  bronchitis  is  common  in  measles,  but  if  it  in- 
crease so  as  to  cause  embarrassment  of  respiration,  and  become  a 
source  of  danger,  it  is  properly  a  complication.  This  complication, 
as  well  as  pneumonia,  may  occur  at  any  period  of  measles,  but  it 
commences  most  frequently  in  the  first  stage.  Occurring  in  the 
fi.rst  stage,  it  may  prevent  the  regular  appearance  of  the  rash ;  if 
in  the  second,  it  often  causes  retrocession  of  it. 

"When  bronchitis  becomes  really  serious,  it  usually  has  invaded 
the  minute  bronchial  tubes.  This  disease,  designated  capillary 
bronchitis  or  sufibcative  catarrh,  I  have  elsewhere  described.  The 
clinical  history  of  fatal  bronchitis,  as  a  complication  of  measles,  is 
as  follows:  The  respiration,  at  first  not  notably  altered,  becomes, 
by  degrees,  accelerated,  and  the  j^atient  more  and  more  fretful. 
The  pulse,  instead  of  becoming  less  accelerated,  as  after  the  first 
days  of  simple  measles,  is  daily  more  rapid,  and  the  respiration 
more  frequent  and  labored.  The  dyspnoea  gradually  increases,  the 
infra-mammary  region  is  depressed  during  each  inspiration,  and 
the  subcrepitant  rale  is  heard  on  both  sides  of  the  chest.  There  is, 
probably,  collapse  or  inflammation  of  some  of  the  lobules.  Finally 
the  prolabia  and  fingers  become  livid,  and  death  occurs  from  apnoea. 
Capillary  bronchitis  is  diagnosticated  from  pneumonitis  by  the 
physical  signs.  It  is  in  the  young  child  more  dangerous  than  that 
disease,  unless  perchance  the  latter  be  double.  A  large  majority 
of  those  afi[*ected  under  the  age  of  three  years,  die.  The  anatomi- 
cal characters  of  fatal  bronchitis  occurring  in  connection  with 
measles,  I  have  had  an  opportunity  to  inspect.  In  an  infant  who 
died  with  this  complication  in  the  Infants'  Hospital  in  the  spring 
of  1867,  there  were  evidences  of  continuous  inflammation  from  the 
epiglottis  to  the  minutest  bronchial  tubes. 

Pneumonia  as  a  complication  does  not  differ  materially  from  the 
idiopathic  form,  except  that  it  is  more  protracted  and  fatal.     Its 


164  MEASLES. 

form  is  in  most  cases  catarrlial,  resulting  from  an  extension  of  the 
bronchial  inflammation. 

The  next  most  frequent  serious  complication  of  measles  is  entero- 
colitis. This  may  commence  at  any  period  during  the  course  of  the 
disease.  If  the  colon  is  more  especially  the  seat  of  inflammation,  the 
evacuations  contain  mucus  and  blood,  unless  in  young  children,  in 
whom  the  stools,  even  in  severe  colitis,  commonly  have  a  green  color. 
The  anatomical  character  of  this  complication  varies  in  diiferent 
cases,  like  the  idiopathic  form  of  inflammation.  Sometimes  there  is 
simple  arborescence  of  the  intestinal  mucous  membrane,  with  tume- 
faction of  its  follicles ;  in  other  cases,  in  addition  to  increased  vas- 
cularity, the  mucous  coat  is  softened  and  thickened ;  and  in  others 
still,  especially  if  the  inflammatory  action  has  been  somewhat  pro- 
tracted, ulceration  occurs,  for  the  most  part  in  the  site  of  the  soli- 
tary glands.  Exceptionally,  in  fatal  cases  of  measles  attended  with 
diarrhcea,  no  vascularity  is  observed  after  death,  although  the 
intestine  may  be  somewhat  thickened  and  softened.  In  these  cases 
the  diarrhoea  may  have  been  non-inflammatory  or  inflammatory, 
the  injection  of  the  vessels  having  disappeared  after  death. 

Severe  and  obstinate  diarrhoeal  afl:ectious  occurring  with  measles, 
usually  commence  as  the  primary  disease  is  about  declining.  They 
then  become  sequelae,  ending  fatally  in  many  instances  several  days 
or  perhaps  weeks  after  the  disappearance  of  the  eruption.  Diar- 
rhoeal attacks,  occurring  in,  or  previously  to,  the  eruptive  stage,  are, 
as  a  rule,  mild  and  easily  relieved. 

In  some  grave  cases,  measles  have  a  tendency  from  the  first  to 
affect  the  internal  organs  more  than  the  surface.  There  then  co- 
exist bronchitis,  pneumonia,  and  entero-colitis,  with  indistinctness 
of  the  eruption  on  the  skin.  Such  complications  render  a  fatal 
result  highly  probable. 

Another  very  fatal  complication  and  sequel  is  true  croup,  com- 
mencing when  rubeola  is  beginning  to  decline ;  but  it  is  less  frequent 
than  pneumonia  or  entero-colitis.  In  catarrhal  or  false  croup,  which, 
as  has  been  previously  stated,  is  not  infrequent  at  the  commencement 
of  measles,  the  cough  has  a  loud,  ringing  character.  In  true  croup, 
on  the  other  hand,  it  is  hoarse  or  harsh,  and  less  distinct,  on  account 
of  the  presence  of  the  pseudo-membrane  in  the  larynx.  True  croup, 
always  a  grave  disease,  is  more  serious  when  it  occurs  as  a  compli- 
cation of  measles  than  in  the  idiopathic  form,  not  only  because  the 
blood  is  vitiated  and  the  system  reduced  by  the  primary  affection, 
but  because  the  inflammation  of  the  mucous  surface  is  in  general 
more  extensive,  as  is  also,  I  believe,  the  pseudo-membrane.     This 


ANATOMICAL    CHARACTERS.  165 

membrane  in  the  croup  of  measles  I  have  seen  extend  so  far  clown 
the  air-passages,  that  tracheotomy  could  not  have  been  attended  by 
any  decided  amelioration  of  symptoms.  This  complication,  though 
always  grave,  is  not,  however,  necessarily  fatal.  I  have  known  cases 
recover  by  ordinary  treatment,  when  for  days  there  had  been  dysp- 
noea and  other  evidences  of  a  pretty  firm  pseudo-membrane.  True 
croup  causes  continuation  of  the  fever,  which  had  perhaps  begun 
to  abate. 

Diphtheria,  when  epidemic,  also  frequently  complicates  measles. 
Much  of  the  mortalit}'  from  measles  in  this  city,  between  the  years 
1860  and  1865,  was  due  to  this  cause.  In  cases  observed  by  myself, 
diphtheria  usually  began  while  the  fauces  were  still  inflamed,  and 
sometimes  before  the  eruption  had  begun  to  fade. 

These  are  the  most  common  complications  of  measles.  There 
are  others  of  less  frequent  occurrence,  among  which  may  be  men- 
tioned congestion  of  the  brain,  with  or  without  serous  eflCusion. 
Stomatitis,  pharyngitis,  and  otitis  are  occasional  complications. 
Rarely,  also,  purpura,  attended  by  hemorrhages  from  the  different 
mucous  surfaces,  occurs  in  connection  wdth  measles.  This  compli- 
cation is,  however,  more  frequent  in  certain  other  constitutional 
diseases,  as  scarlet  fever,  and  especially  variola. 

It  is  seen  that  the  inflammations  which  are  apt  to  occur  in  the 
course  of  measles  are  chiefly  of  the  mucous  surfaces.  In  scarlet 
fever,  on  the  other  hand,  the  inflammations  are  serous. 

There  are  other  affections,  originating  in  measles,  which  are 
rather  sequelae  than  complications.  Gangrene  of  the  mouth  is  one 
which,  as  stated  in  another  part  of  the  work,  is  more  apt  to  occur 
after  measles  than  any  other  disease.  Ophthalmia  commencing  in 
measles  often  persists  for  weeks  or  months.  It  may  give  rise  to 
granulations  of  the  lids,  and  cases  have  been  reported  of  violent 
inflammation  of  a  purulent  character,  producing  ulceration  of  the 
cornea,  and  destroying  vision.  The  ophthalmia  is  sometimes  very 
intractable.  Inflammation  of  the  Schneiderian  membrane,  com- 
monly present  during  measles,  sometimes  continues  as  a  sequel,  ex- 
tending back  as  far  as  the  Eustachian  tube,  where  it  may  cause 
swelling,  with  impairment  of  hearing,  and  forward  to  the  lip, 
where  it  may  produce  chronic  eczema. 

Anatomical  Characters. — I  have  made,  or  witnessed,  according 
to  remembrance,  some  six  post-mortem  examinations  of  those  who 
have  died  in,  or  immediately  after,  an  attack  of  measles.  In  all 
there  were  lesions  due  to  complications.  Indeed,  death  directly 
from  measles  is  so  rare  that  few  have  had  an  opportunity  of  study- 


166  MEASLES. 

ing  the  anatomical  characters  which  are  peculiar  to  this  affection. 
In  those  who  have  died  without  any  obvious  coexisting  disease, 
and  these  cases  chiefly  occur  in  the  malignant  form,  there  has  been 
congestion  of  the  internal  organs,  especially  marked  in  the  lungs, 
and  sometimes  the  tissues  appeared  softened.  The  blood,  also,  in 
the  malignant  form,  has  a  darker  hue  than  natural,  and  ecchymotic 
patches  have  been  observed  upon  the  mucous  surfaces  and  elsewhere, 
corresponding  in  character  with  the  petechise  under  the  skin  which 
sometimes  occur  in  this  form  of  measles.  In  cases  resulting  fatally 
from  bronchitis  or  pneumonia  the  bronchial  glands  are  commonly 
tumefied  in  the  same  manner  as  the  mesenteric  glands  are  enlarged 
in  enteritis,  and  the  glands  of  the  meso-colon  in  dysentery. 

I!s'ature. — Rubeola,  like  the  other  exanthematic  fevers,  is  due  to 
a  materies  morbi,  the  exact  nature  of  which  is  unknown.  It  is 
both  inoculable  and  infectious.  It  has  been  inoculated  by  the 
serum  from  vesicles  which  sometimes  occur  in  connection  with  the 
rubeolous  eruption,  and  also  by  the  blood  from  a  patient.  Inocu- 
lation does  not  appear  to  moderate  the  disease,  and  as  measles, 
when  contracted  in  the  ordinary  way,  is  not  in  itself  dangerous, 
but  dangerous  only  from  complications,  inoculation  is  not  per- 
formed, except  as  a  matter  of  scientific  interest.  The  usual  mode 
of  propagation  is  by  infection.  It  is  communicated  both  by  the 
breath  and  clothing.  By  fomites  the  virus  is  sometimes  conveyed 
a  long  distance.  The  question  is  still  undecided  whether  rubeola 
does  not  sometimes  occur  spontaneously.  I  have  met  cases,  and 
have  been  informed  of  others,  one  especially,  occurring  in  a  sparsely 
settled  portion  of  the  country,  in  which  there  was  apparently  no 
exposure,  and  I  incline  to  the  opinion  that  its  origin  de  novo  is 
possible,  though  not  frequent. 

The  period  of  incubation  of  measles  is  usually  from  ten  to  four- 
teen days.  In  cases  observed  in  the  children's  department  of 
Charity  Hospital,  this  period  was  ascertained  to  be  about  twelve 
days.  In  those  who  have  been  inoculated,  the  incubative  period 
is  said  to  have  been  about  one  week.  Rubeola  prevails  epidemi- 
cally, like  the  whole  class  of  infectious  diseases,  and  in  dififerent 
epidemics  the  type  varies  somewhat,  as  well  as  the  character  of 
the  complications. 

Diagnosis. — The  diagnosis  of  measles,  previously  to  the  eruption, 
is  often  difficult.  The  catarrhal  symptoms  then  predominate,  and 
these  are  such  as  may  occur  independently  Qf  any  constitutional 
or  blood  disease.  The  first  stage,  therefore,  of  measles,  is  often 
mistaken  for  coryza,  or  mild  bronchitis.     The  points  of  difterential 


PROGNOSIS  —  TREATMENT.  167 

diagnosis  are  the  suffused  appearance  of  the  eyes,  tlie  greater  degree 
of  fever  on  tlie  first  day  than  would  be  likely  to  arise  from  so 
moderate  an  amount  of  local  disease,  and  on  subsequent  days  re- 
mission and  exacerbation  of  the  fever.  Measles  in  the  first  stage 
has  been  mistaken  for  remittent  fever.  The  catarrhal  symptoms 
should  prevent  such  an  error. 

Sometimes  roseola  closely  resembles  measles  in  appearance,  but 
the  rash  of  roseola  appears  within  a  few  hours  after  the  commence- 
ment of  febrile  symptoms,  and  almost  simultaneously  over  the 
whole  body,  and  without  those  local  symptoms  referable  to  the 
mucous  surfaces,  which  characterize  measles. 

Variola  on  the  first  day  of  the  eruption  has  sometimes  been 
diagnosticated  as  measles.  I  recollect  once  being  called  to  an  in- 
fant with  fatal  confluent  smallpox,  who  was  said  to  have  measles. 
A  physician,  a  few  days  previously,  observing  the  red  points  in  the 
commencement  of  the  eruption,  had  made  this  absurd  diagnosis, 
and,  predicting  a  favorable  result,  had  not  thought  it  necessary  to 
repeat  his  visit.  In  case  of  doubt,  it  is  the  part  of  prudence  to 
defer  making  a  positive  diagnosis.  A  few  hours  sufiice  to  show 
the  distinctive  characters  of  the  rubeolous  and  variolous  eruptions. 
But  the  anxiety  of  friends  often. necessitates  the  expression  of  an 
opinion.  The  absence  of  catarrhal  symptoms,  the  earlier  appear- 
ance of  the  eruption,  and  its  papular  feel  under  the  finger  in 
smallpox,  enable  us  to  discriminate  between  the  two  diseases  in 
the  commencement  of  the  eruptive  stage.  Moreover,  the  symp- 
toms in  the  initial  periods  are  different,  as  will  be  seen  in  our 
description  of  smallpox. 

Prognosis. — This  is  favorable,  provided  that  there  is  no  serious 
complication.  "With  internal  inflammatory  complication,  on  the 
other  hand,  the  disease  becomes  much  more  grave.  A  large  pro- 
portion thus  affected  die.  The  prognosis  is  also  less  favorable  in 
feeble  children  with  scanty  eruption,  or  an  eruption  appearing  at 
a  late  period  and  irregularly.  Dyspnoea,  persistent  and  great, 
acceleration  of  pulse,  and  coma,  indicate  an  unfavorable  ending. 
Convulsions  occur  much  more  rarely  in  the  course  of  measles  than 
in  scarlet  fever,  and  when  they  occur  after  the  initial  period  they 
usually  end  in  coma  and  death. 

Treatment. — ^Uncomplicated  measles  requires  no  medicinal  treat- 
ment except  to  palliate  symptoms.  The  child  should  be  kept  in 
an  airy  apartment,  at  a  uniform  temperature  of  about  68°.  A 
temperature  so  elevated  as  to  be  uncomfortable  to  the  nurse  is 
injurious  to  the  patient.     But  while  the  popular  idea  is  erroneous, 


168  MEASLES. 

that  Le  should  be  kept  in  a  heated  atmosphere,  it  is  correct  that 
currents  of  air  and  sudden  reduction  of  temperature  are  dangerous. 
A  violent  and  fatal  attack  of  croup  occurred  in  my  practice  in  a 
girl  of  fifteen,  in  consequence  of  exposure  at  an  open  window 
during  the  j)eriod  of  desquamation..  The  diet  should  be  mild,  and 
for  the  most  part  liquid.  The  patient,  indeed,  refuses  solid  food, 
but,  on  account  of  the  thirst,  takes  liquids  more  readily.  Farina- 
ceous substances,  with  milk,  afford  sufficient  nutriment  in  ordinary 
cases.  If  the  previous  health  has  been  poor  and  the  vital  powers 
reduced,  or  if  there  is  a  complication,  more  sustaining  diet  is  re- 
quired. Stimulation  by  wine  or  brandy  is  needed  in  some  of  these 
cases.  During  the  two  or  three  weeks  succeeding  an  attack  of 
measles,  care  should  be  taken  to  avoid  exposure  to  cold,  or  changes 
of  temperature,  since  during  this  period  mucous  inflammations  are 
so  apt  to  occur. 

The  cough  in  most  cases  requires  treatment,  inasmuch  as  the 
suffering  of  the  child  and  loss  of  sleep  are  largely  due  to  this 
symptom.  Demulcent  drinks,  as  flaxseed  tea,  infusion  of  slippery- 
elm  bark,  or  solution  of  gum  Arabic,  are  useful,  to  which,  to  render 
them  more  palatable,  lemon-juice  may  be  added.  A  small  Dover's 
powder,  or  the  following  mixture  given  occasionally,  relieves  the 
severity  and  diminishes  the  frequency  of  the  cough : — 

I^.  Tinct.  opii  camphorat., 
Syr.  scillse, 
Syr.  ipecac,  aa  533; 
Spts.  fetlier.  nitr.  5ij-'    Misce. 
Dose,  one  teaspoonful  to  a  child  of  five  years,  repeated  according  to  circumstances. 

As  the  chief  danger  in  measles  is  from  inflammation  of  the  respi- 
ratory organs,  local  treatment  directed  to  the  chest  is  important. 
The  chest  should  be  covered  with  oil-silk,  unless  in  the  mildest 
cases.  This  increases  the  amount  of  eruption  upon  the  surface 
underneath,  and,  I  believe,  tends  greatly  to  prevent  complication 
by  bronchitis  and  pneumonia.  If  the  eruption  is  tardy  in  its 
appearance,  or  indistinct,  it  is  well  to  produce  moderate  counter- 
irritation  by  some  gentle  irritant  underneath,  as  camphorated  oil, 
to  which  one-third  part  of  turpentine  is  added. 

Affections,  which  complicate  measles,  should  receive,  for  the 
most  part,  such  treatment  as  is  approj^riate  for  them  when  idio- 
pathic. Secondary  diseases,  however,  require  sustaining  measures 
more  than  primary.  In  bronchial  and  pulmonary  inflammations, 
which,  if  they  occur  early  in  measles,  prevent  the  regular  appear- 
ance of  the  eruption,  or,  if  in  the  eruptive  stage,  cause  its  disap- 


SCARLET    FEVER.  169 

pearance,  itrompt  counter-irritation  over  the  chest,  by  sinapisms  or 
otherwise,  is  required.  Trousseau  states  that  he  has  derived  benefit 
in  tliese  cases,  from  what  he  designates  urtication.  This  is  pro- 
duced by  stroking  the  chest  two  or  three  times  daily  with  the 
nettle  (urtica  dioica  or  urtica  urens).  This  causes  a  prompt  and 
abundant  eruption,  and  with  a  less  amount  of  suffering  than 
one  would  suppose.  The  fever  abates,  and  the  respiration  becomes 
more  natural  in  proportion  to  the  amount  of  nettle-rash.  On  the 
second  day  the  effect  is  less  than  on  the  first,  and  after  three  or 
four  days,  says  Trousseau,  no  further  irritation  results  from  the 
nettle.  When  counter-irritation  is  produced,  by  whatever  method, 
the  chest  should  be  covered  with  a  warm  and  soft  poultice,  as  the 
ground  flaxseed;  derivatives  to  the  extremities  are  useful  in  such 
cases.  In  capillary  bronchitis  and  pneumonia  stimulating  expec- 
torants are  required,  as  senega  and  carbonate  of  ammonia. 

As   regards   the  treatment  of  other  complications,  the  appro- 
priate measures  are  detailed  elsewhere. 


CHAPTERIL 

SCARLET  FEVER. 

The  terms  scarlet  fever,  scarlet  rash,  and  scarlatina  are  identical. 
They  are  employed  to  designate  one  of  the  most  frequent  and  fatal 
of  the  contagious  diseases,  a  disease  which  may  occur  at  any  age,  but 
is' most  common  in  childhood,  an  exanthem  attended  with  more  or 
less  pharyngitis.  In  this  city,  on  account  of  its  great  frequency, 
and  its  large  percentage  of  fatal  cases,  it  causes  more  deaths  than 
any  other  contagious  affection.  Though  not  more  common  than 
measles,  it  is  attended,  with  us,  by  more  than  double  its  mortality. 

There  is  no  disease  that  presents  a  greater  difference,  as  regards 
character  and  severity  of  symptoms,  than  scarlet  fever,  and  this 
has  led  to  the  recognition  of  different  forms  of  it.  Rilliet  and 
Barthez  describe  two,  the  normal  and  abnormal ;  Meigs  two,  the 
mild  and  grave ;  and  most  other  writers,  three  or  more.  I  shall,  for 
convenience,  follow  Bouchut,  who  makes  three  varieties,  namely, 
the  regular,  irregular,  and  malignant. 

Symptoms.  Begular  Form. — Scarlet  fever  usually  begins  ab- 
ruj)tly.      It  is  possible,  often,  to  tell  the  exact  time  of  its  com- 


170  SCARLET    FEVER. 

mencement.  If  there  are  premonitory  symptoms,  they  are  ordi- 
narily slight,  so  as  scarcely  to  attract  attention,  amounting  to  little 
more  than  dulness,  or  the  appearance  of  fatigue.  In  some  the  first 
symptom  is  chilliness,  and  occasionally  a  distinct  chill  is  experi- 
enced. This  is  the  ordinary  mode  of  commencement  in  the  adult. 
With  or  without  the  chilliness,  fever,  usually  intense,  arises,  , 
accompanied  by  such  symptoms  as  ordinarily  occur  in  a  febrile 
state  of  system,  such  as  cephalalgia,  perhaps  delirium,  anorexia, 
thirst.  The  pulse  rises  to  110,  120,  or  more,  per  minute;  the  skin 
is  hot,  face  flushed,  the  eyes  bright,  and  occasionally  more  or  less 
suffused.  In  many,  there  is  sudden  starting  or  twitching,  with  a 
degree  of  stupor,  showing  that  the  cerebro-spinal  system  is  pro- 
foundly affected. 

In  most  cases  there  occurs  within  the  first  twenty-four  hours 
a  symptom  which  has  considerable  diagnostic  value,  namely, 
vomiting.  In  117  cases  in  which  I  have  recorded  its  presence  or 
absence,  it  occurred  in  90,  usually  not  at  the  very  commencement, 
but  within  the  first  twelve  or  eighteen  hours.  It  commonly 
occurred  before  the  appearance  of  the  rash,  but  not  always.  In 
a  few  of  the  cases  it  is  recorded  as  a  symptom  of  the  second  da3^ 
Vomiting  at  this  period  is,  probably,  in  most  cases,  sympathetic, 
due  to  the  effect  of  the  specific  virus  of  the  disease  on  the  brain. 
It  is  not  a  severe  symptom,  occurring  in  most  cases  but  once  or 
twice.  Great  and  persistent  irritability  of  stomach  indicates  a 
serious  form  of  scarlet  fever,  and  is,  therefore,  prognostic  of  an 
unfavorable  ending.  "When  this  symptom  is  absent  or  slight,  or 
there  is  merely  nausea,  I  have  found  the  case  ordinarily  mild,  so 
that,  as  regards  the  frequency  of  vomiting,  the  statistics  of  differ- 
ent epidemics  vary  according  to  the  mildness  or  gravity  of  the 
type.  The  bowels  are  regular  or  somewhat  constipated  in  this 
form  of  scarlet  fever,  or  if  diarrhoea  occur,  it  is  slight  and  tran- 
sient. 

When  the  symptoms  described  above  have  continued  six  to  eigh- 
teen hours,  the  rash  appears.  It  is  first  observed  about  the  ears, 
neck,  and  shoulders,  in  reddish  indistinct  patches,  fading  into  the 
normal  hue.  These  patches  extend  and  unite,  and  in  the  course  of 
a  few  hours  the  trunk  and  upper  extremities,  and  finally  the  legs, 
are  covered.  The  scarlatinous  rash  bears  considerable  resemblance 
to  that  produced  by  external  heat  or  the  redness  from  a  sinapism, 
but  there  are  numerous  minute  points  of  a  deeper  or  duskier  red 
than  the  surface  generally.  On  passing  the  finger  over  the  erup- 
tion, no  distinct  prominences  are  observed,  but  a  sensation  of  rough- 


SYMPTOMS.  171 

noss  is  sometimes  imparted  from  engorgement  of  the  cutaneous  pa- 
pilljie.  The  rash  disappears  by  pressure,  but  in  robust  children, 
and  in  favorable  cases,  it  immediately  returns  when  the  pressure  is 
removed.  Slow  return  of  the  rash  is  evidence  of  sluijirish  circula- 
tion,  and,  when  marked,  it  indicates  the  malignant  form  of  the 
disease.  The  rash  gives  rise  to  an  itching  or  burning  sensation, 
which  adds  greatly  to  the  discomfort  of  the  patient.  The  degree 
of  redness  is  not  uniform  over  the  surface,  and  sometimes,  especially 
in  mild  cases,  it  is  absent  in  places. 

Early  in  the  disease,  even  before  the  cutaneous  eruption,  the  buc- 
cal and  faucial  mucous  membrane  presents  a  pretty  general  red 
appearance,  and  the  papillae  of  the  tongue  are  elevated.  Pharyn- 
gitis has  already  commenced,  with  more  or  less  stomatitis  and  tonsil- 
litis. The  inflammation  renders  deglutition  painful,  so  that  diffi- 
culty is  often  experienced  in  giving  the  necessary  drinks.  This 
state  of  the  buccal  and  faucial  membrane  continues  through  the 
disease.  There  is  sometimes  a  slight  fibrinous  exudation  over  the 
tonsils ;  the  tongue  is  covered  with  a  moist  fur,  and  the  secretion 
from  the  follicles  of  the  inflamed  surface  is  increased  and  muco- 
purulent. The  Schneiderian  membrane  also  participates  in  the 
inflammation,  and,  as  the  disease  advances,  a  thin,  irritating  dis- 
charge, containing  pus  cells,  flows  from  the  nostrils. 

The  temperature  in  the  first  days  of  scarlet  fever  is  ordinarily 
from  102°  to  105°,  sometimes  as  high  as  107°.  The  cutaneous  trans- 
piration during  this  period  is  nearly  checked,  so  that  the  skin  is  hot 
and  dry.  The  respiration  is  moderately  accelerated,  but  not  so  as 
to  attract  attention,  unless  there  is  a  complication ;  often  there  is 
slio-ht  couo-h  from  mucus  in  the  throat  or  bronchial  tubes.  Bron- 
chitis,  common  in  measles,  and  giving  rise  to  prominent  symp- 
toms in  that  disease,  is  either  absent  or  slight  in  scarlet  fever. 

The  symptoms  pertaining  to  the  digestive  system  during  the 
initial  period  of  scarlet  fever  have  been  sufficiently  described.  The 
subsequent  symptoms  do  not  difl'er  materially  in  regular  scarlet 
fever,  except  that  there  is  no  vomiting.  The  lips  are  dry  and  often 
cracked.  The  inflammation  of  the  mouth  and  throat  continues 
unabated,  with  anorexia  and  thirst.  The  urine  is  high-colored,  and 
in  robust  children,  during  the  first  days  of  scarlet  fever,  it  fre- 
quently deposits  the  urates  on  cooling. 

The  symptoms  continue  with  undiminished  intensity  for  a  period 
of  from  four  to  six  days,  when  the  fever  begins  to  abate,  the  pun- 
gent heat  becomes  less,  and  the  rash  fainter.     There  is  a  gradual 


172  SCARLET    FEVER. 

decline  of  the  disease,  which,  in  its  inception,  was  so  abrupt.  In 
mild,  and  even  pretty  severe  cases,  which  pursue  a  regular  and 
favorable  course,  convalescence  commences  by  the  close  of  the  first 
or  beginning  of  the  second  week.  In  the  second  week,  the  rash, 
becoming  less  and  less  distinct,  finally  disappears,  as  do  also  the 
redness  and  swelling  of  the  buccal  and  faucial  membrane.  The 
engorgement  of  the  papillae  of  the  tongue  and  that  of  the  tonsils 
subsides;  the  appetite  returns;  the  countenance  brightens,  and  be- 
comes natural,  and  the  child  who,  during  the  height  of  the  fever, 
scarcely  noticed  objects,  or  noticed  them  with  indifference,  or  even 
repugnance,  can  be  amused  as'before  his  sickness. 

The  period  of  desquamation  succeeds.  Exfoliation  of  the  epi- 
dermis occurs  over  the  whole  body.  This  commences  about  the 
face  and  neck,  and  it  occupies  several  days,  during  which  there  is 
progressive  improvement  in  the  condition  of  the  child.  Where 
the  skin  is  thin,  the  epidermis,  as  it  is  detached,  presents  a  furfu- 
raceous  appearance;  where  it  is  thick,  as  upon  the  palms  of  the 
hands,  and  soles  of  the  feet,  it  separates  in  a  layer  of  considerable 
thickness. 

Sach  is  a  brief  account  of  scarlet  fever,  when  it  pursues  its  nor- 
mal course,  without  complication  or  sequelee.  But  there  is  no  dis- 
ease which  has  so  many  unfavorable  complications  and  sequelee  as 
this.  The  liability  to  these  renders  the  prognosis  in  all  cases  doubt- 
ful, and  in  many  instances  they  are  the  immediate  cause  of  death. 
They  occur  both  in  mild  and  severe  cases  of  scarlet  fever. 

The  great  difference  in  different  cases  of  scarlet  fever,  as  regards 
intensity  of  symptoms,  is  well  known.  It  is  sometimes  so  mild, 
its  characteristic  features  so  slight,  that  diagnosis  is  necessarily 
uncertain.  Examples  in  corroboration  of  this  statement  are  not 
infrequent.  In  the  spring  of  1866  I  was  called  to  an  infant  thir- 
teen months  old,  who  had  slight  pharyngitis,  and  an  indistinct 
rash  over  a  part  of  the  surface.  In  two  days  the  eruption  had 
disappeared,  and  soon  after  the  health  was  apparently  fully  restored. 
Diagnosis  would  have  remained  doubtful,  except  for  sequelse.  In 
another  instance,  two  children  passed  through  the  entire  course  of 
scarlet  fever,  playing  every  day  in  the  street.  Although  the  intel- 
ligent grandmother  saw  the  rash  upon  them,  its  nature  was  not 
suspected  till  nearly  two  weeks  afterwards,  when  one  was  taken 
with  fatal  nephritis  and  general  anasarca.  In  cases  so  mild  as 
these,  the  heat  of  surface  is  not  greatly  increased,  nor  is  the  pulse 
much  accelerated.  There  is  no  restlessness,  nor  is  the  digestive 
function  materially  impaired.     The  rash  does  not  have  so  deep  a 


SYMPTOMS.  173 

color,  nor  is  it  so  continuous  over  the  surface,  as  in  cases  of  ordinary 
gravity.  The  patient  begins  to  improve  in  from  two  to  four  days, 
and  is  soon  well.  So  mild  a  form  of  scarlet  fever  is,  however,  quite 
exceptional,  but  there  are  all  gradations,  from  this  mildness  to  that 
malignant  form  which  I  shall  presently  describe. 

There  is  usually  considerable  faucial  inflammation,  even  when 
scarlet  fever  pursues  a  regular  and  favorable  course.  If  the  pharyn- 
gitis is  intense  and  protracted,  many  writers  designate  the  disease 
scarlatina  anginosa.  There  is,  in  these  cases,  not  only  general  and 
pretty  severe  inflammation  of  the  mucous  membrane  of  the  fauces, 
with  swelling  of  the  tonsils,  and  submucous  infiltration,  but  also 
more  or  less  tumefaction  around  the  angle  of  the  jaw,  due  to  exten- 
sion of  the  inflammation  to  the  lymphatic  glands,  and  cellular  tissue 
of  the  neck.  In  these  cases,  the  suflering  of  the  patient  is  greatly 
increased  by  the  amount  of  local  disease.  The  adenitis  and  cellu- 
litis, unless  slight,  do  not  subside  with  the  disappearance  of  the 
rash,  or  they  subside  more  slowly.  They  render  the  febrile  move- 
ment more  protracted.  The  swelling  due  to  these  inflammations 
often  continues  one  or  two  weeks  after  the  disappearance  of  the 
rash,  or  even  longer,  when  it  disappears  by  resolution,  or  more 
rarely  by  suppuration,  the  abscess  opening  externally. 

Irregular  Form. — The  irregular  form  of  scarlet  fever  is  commonly 
due  to  some  perturbating  cause.  This  cause  is  often  a  pre-existing 
or  coexisting  disease,  or,  if  not  actual  disease,  at  least  disordered 
state  of  system.  For  example,  a  little  girl,  in  my  practice,  had  the 
symptoms  of  scarlet  fever,  such  as  febrile  movement  and  inflamma- 
tion of  the  buccal  and  faucial  surface,  nearly  a  week  before  the 
scarlatinous  eruption  appeared.  During  this  period  there  were 
symptoms  of  enteritis,  which  declined  when  the  rash  occurred.  The 
abdominal  affection  was  the  apparent  cause  of  the  irregularity  in 
the  fever.  If  scarlet  fever  occurs  during  an  attack  of  entero-colitis, 
there  is  frequently  no  eruption.  Most  practitioners  have  met  cases 
like  the  following,  which  I  now  recall  to  mind:  In  a  family  where 
scarlet  fever  was  prevailing,  a  little  child,  early  after  the  commence- 
ment of  symptoms  which  seemed  to  be  plainly  referable  to  the  ex- 
anthematic  affection,  was  seized  with  vomiting  and  purging,  and  the 
latter  continued  two  or  perhaps  three  days,  when  death  occurred. 
There  were  the  symptoms  and  appearances  of  severe  scarlet  fever, 
but  without  the  eruption.  In  another  instance,  an  infant  in  the 
warm  months  having  protracted  entero-colitis,  the  usual  summer 
epidemic  of  this  city,  was  apparently  affected  with  scarlet  fever, 


174  SCARLET    FEVER. 

which  was  present  in  the  family.     There  were  the  characteristic 
symptoms,  but  the  diarrhoea  continued,  and  there  was  no  rash. 

In  those  that  are  much  reduced  by  any  antecedent  disease,  as 
phthisis,  or  that  have  a  disease,  chronic  or  acute,  which  produces 
a  decided  afflux  of  blood  towards  an  internal  organ,  the  eruption  is 
commonly  tardy  in  its  appearance,  indistinct,  or  wholly  absent. 
The  diseases  which  most  frequently  render  scarlet  fever  irregular 
are  those  of  an  inflammatory  nature.  Some  affections,  occurring 
in  connection  with  scarlet  fever,  do  not  change  its  symptoms,  but 
themselves  undergo  modification.  Scarlet  fever  occurring  in  a  child 
having  pertussis  does  not  itself  undergo  any  material  change.  The 
cough,  not  the  fever,  is  modified  (rendered  milder)  during  the 
coexistence  of  the  two. 

Scarlet  fever  may,  also,  be  irregular  in  those  that  are  robust  and 
free  from  any  other  disease  assuming  this  form,  without  any  appre- 
ciable perturbating  cause.  In  1867  I  attended  a  young  lady,  whose 
previous  health  was  excellent,  and  whose  brother  was  sick  at  the 
time  with  scarlet  fever.  This  patient  had  considerable  fever,  with 
pretty  severe  pharyngitis,  and  though  her  surface  was  repeatedly 
examined,  no  eruption  could  be  discovered.  Two  weeks  subse- 
quently she  became  affected  with  severe  nephritis,  anasarca,  effu- 
sion into  at  least  one  of  the  pleural  cavities,  and  probably  into  the 
pericardium,  the  case  ending  fatally. 

Rilliet  and  Barthez  mention  the  irregular  and  incomplete  char- 
acter of  the  eruption  in  second  attacks  of  scarlet  fever,  which, 
though  uncommon,  are  met  from  time  to  time.  Scarlet  fever 
occurring  a  second  time,  sometimes  presents  all  the  features  of  the 
regular  disease,  and  pursues  its  normal  course,  but  it  is  much  more 
apt  to  be  incomplete  and  irregular  than  the  first  attack.  It  is 
more  apt  to  be  irregular  if  the  interval  between  the  two  has  been 
short,  than  if  several  years  have  elapsed. 

Malignant  Form. — This  form  of  scarlet  fever  is  in  some  epidemics 
common,  while  in  others  it  is  rare.  It  usually  commences  with 
severe  symptoms,  those  pertaining  to  the  nervous  system  predomi- 
nating, such  as  intense  cephalalgia,  with  delirium.  Many  pass 
rapidly  into  coma,  and  die  within  two  or  three  days.  They  suc- 
cumb to  the  virulence  of  the  scarlatinous  poison,  while  the  disease 
is  still  in  its  commencement.  The  rash  in  malignant  scarlet  fever 
is  dusky.  It  disappears  by  pressure,  and  returns  slowly  when  the 
pressure  is  removed.  Tliere  is,  therefore,  extreme  sluggishness  of 
the  capillary  circulation.  In  some  there  is  great  restlessness.  If 
placed  in  one  position  on  the  bed,  they  soon  throw  themselves,  in  a 


COMPLICATIONS.  175 

half-conscious  or .  unconscious  state,  into  another.  They  do  not 
speak  at  all,  or  they  mutter  like  those  affected  hy  the  graver  forms 
of  typhus,  calling  the  names  of  playmates,  or  talking  about  things 
which  interested  them  when  well.  There  is  great  elevation  of 
temperature,  the  thermometer,  placed  in  the  axilla,  indicating  103°, 
105°,  or  even  107°,  and  the  heat  of  surface  is  pungent,  except  when 
the  case  approaches  a  fatal  termination.  The  pulse  from  the  first 
is  rapid,  numbering  from  130  to  160  per  minute.  Sometimes  there 
is  great  heat  of  head  and  body,  while  the  limbs  are  cool.  This  is 
an  unfavorable  sign. 

Severe  and  dangerous  nervous  symptoms,  as  convulsions  and 
coma,  occur  chiefly  within  the  first  three  or  four  days.  After  this 
period  the  danger  is  mainly  from  exhaustion.  Those  who  survive 
the  onset  of  the  disease,  often  have,  in  the  course  of  a  few  days, 
severe  pharyngitis,  with  inflammation  of  the  lymphatic  glands,  and 
cellular  tissue  around  the  angle  of  the  jaw,  accompanied  by  external 
swelling.  The  pharyngitis  is  attended  by  more  or  less  secretion  of 
mucus  or  muco-pus,  which,  sometimes  collecting  around  the  en- 
trance of  the  larynx,  causes  noisy  respiration,  or  even,  if  the  system 
is  greatly  prostrated,  embarrasses  respiration  by  entering  the  larynx. 
The  chief  danger,  however,  from  the  pharyngitis,  is  due  to  the 
exhaustion  which  it  causes.  By  rendering  deglutition  difficult,  it 
interferes  seriously  with  nutrition. 

Complications. — Complications  may  occur  in  any  form  of  scarlet 
fever,  but  they  are  most  frequent  in  malignant  or  grave  cases.  The 
most  common  and  serious  complication,  as  regards  the  nervous 
system,  is  clonic  convulsions.  These  occasionally  occur  at  the  com- 
mencement of  the  disease,  before  the  appearance  of  the  rash,  and 
many  then  recover,  but  I  have  not  seen,  nor  have  I  heard,  in  nly 
intercourse  with  physicians,  of  any  case  which  recovered  when  con- 
vulsions occurred  after  the  complete  development  of  the  eruption. 
On  the  other  hand,  some  of  the  physicians  of  this  city,  of  largest 
experience,  inform  me  that  they  consider  convulsions  during  the 
eruptive  stage  an  almost  certain  precursor  of  death.  Convulsive 
attacks  in  scarlatina  are  probably  due,  in  part,  to  congestion  of  the 
nervous  centres,  for  we  sometimes  find,  in  young  children,  at  the 
time  of  the  seizure,  and  immediately  before  it,  the  anterior  fonta- 
nelle  prominent,  and  forcibly  pulsating.  The  convulsions  uniformly 
increase  the  congestion,  but,  as  the  latter  antedates  the  former,  its 
causative  relation  seems  to  be  established.  But  the  most  important 
element  in  the  causation  of  convulsions  in  scarlet  fever  is,  probably, 
the  presence  in  the  blood  of  the  scarlatinous  virus.    This,  whatever 


176  SCARLET    FEVER. 

its  exact  nature,  may,  in  my  opinion,  cause  convulsions,  with  or 
without  the  co-operating  influence  of  congestion,  as  urea  gives  rise 
to  them  in  cases  of  uraemia.  Convulsions  occurring  at  the  com- 
mencement of  scarlet  fever  are  usually  single.  If  repeated,  they 
become  more  serious.  Convulsions  after  the  appearance  of  the 
eruption,  either  end  at  once  in  coma,  or  they  return  at  short  inter- 
vals, with  gradually  increasing  drowsiness,  till  coma  supervenes. 

The  anginose  aftection  in  scarlet  fever  may  be  so  severe,  or  assume 
such  features,  as  to  constitute  a  complication.  It  may  become  more 
serious  than  the  primary  disease  itself,  so  as  to  require  the  chief 
treatment.  During  the  recent  epidemic  of  diphtheria  in  this  city 
many  cases  were  observed  in  which  diphtheria  and  scarlet  fever 
coexisted.  As  has  been  stated  elsewhere,  a  pseudo-membranous 
formation  upon  the  faucial  surface,  especially  over  the  tonsils,  is 
not  uncommon  in  severe  anginose  scarlet  fever,  but  is  soft  or  pulta- 
ceous,  in  isolated  points  or  patches,  and  easily  detached.  On  the 
other  hand,  in  the  cases  to  which  I  have  alluded,  of  diphtheritic 
complication,  the  pseudo-membrane  is  firm  and  thick,  penetrating 
the  mucous  membrane  so  as  to  produce  bleeding  when  forcibly  de- 
tached, as  in  primary  diphtheria.  In  one  instance  in  my  practice 
the  coexistence  of  diphtheria  and  scarlet  fever  was  very  apparent. 
Two  children  in  a  family  died  after  a  short  attack  of  malignant 
scarlet  fever.  Their  throats  were  not  examined.  Another  child 
took  the  disease,  and,  being  longer  sick,  it  was  more  carefully  ex- 
amined. The  diphtheritic  pseudo-membrane  was  found  on  both 
tonsils,  at  the  same  time  that  there  was  a  distinct  scarlatinous  rash, 
and,  as  additional  proof  of  the  coexistence  of  the  two  diseases,  the 
father  became  aifected  with  diphtheria  without  scarlatina. 

An  occasional  result  of  severe  pharyngitis  in  scarlet  fever  is 
suppuration,  or  gangrene  occurring  in  the  subcutaneous  cellular 
tissue  of  the  neck.  Whether  suppuration  occur,  and  an  abscess 
form,  or  gangrene  result,  this  complication  is  often  serious.  Sup- 
puration or  gangrene  indicates  an  intense  grade  of  inflammation 
or  a  low  vitality ;  but  many  with  this  complication  recover  through 
protracted  convalescence. 

If  suppuration  is  extensive,  it  may  so  increase  the  debility  that 
death  occurs  in  consequence.  Gangrene  is  a  more  serious  compli- 
cation; unless  slight,  it  renders  a  fatal  termination  highly  probable. 
The  areolar  tissue,  subcutaneous  or  intermuscular,  is  the  part 
which  primarily  sloughs.  The  skin  over  the  gangrene  becomes 
brown  or  dark,  and  separates  with  the  slough.  In  the  majority  of 
cases  the  slough  is  not  large.     Exceptionally  it  extends  so  deeply 


I 


COMPLICATIONS.  177 

that,  when  it  separates,  the  muscles  and  even  vessels  of  the  neck 
arc  laid  bare,  and  the  appearance  is  hideous.  In  a  case  of  this  sort, 
which  I  saw  a  few  years  since  in  the  practice  of  another  physician, 
the  cavity,  after  the  slough  had  separated,  was  irregular,  and 
sufficiently  large  to  admit  a  hen's  egg.  It  extended  a  considerable 
distance  out  of  sight  under  the  skin,  and  finally  opened  a  vessel 
from  which  fatal  hemorrhage  occurred. 

Gangrene  of  the  mouth  also  occurs  in  rare  instances,  either  as 
a  complication  or  sequel.  I  have  met  it  in  two  cases,  one  of 
which  recovered.  In  the  fatal  case  it  began  while  the  patient  was 
still  under  treatment  for  the  fever,  and  was  first  discovered  by  the 
loss  of  two  incisors.  The  one  that  recovered  also  lost  two  in- 
cisors, and  a  part  of  the  superior  maxillary  bone.  The  one  that 
died  was  scrofulous,  though  its  regimen  was  good ;  the  other  lived 
in  a  tenement-house,  and  was  ill  cared  for.  Rilliet  and  Barthez 
relate  three  cases  of  gangrene  of  the  mouth,  occurring,  however, 
not  as  a  complication,  but  sequel,  of  scarlet  fever.  One  of  these 
patients  had,  within  eighteen  days,  varioloid,  scarlet  fever,  and 
measles ;  these  diseases  ending  in  fatal  gangrene  of  the  pharynx 
and  mouth.  The  second  child  was  taken,  on  the  seventeenth  day 
after  the  commencement  of  scarlet  fever,  with  gangrene  of  the 
pharynx,  succeeded  by  that  of  the  mouth,  and  died  on  the  twenty- 
fourth  day.  In  the  third  case  the  gangrene  was  preceded  by  small- 
pox as  well  as  scarlatina.     Other  observers  have  recorded  similar 

CclSGS, 

Another  complication,  to  which  allusion  has  already  been  made, 
is  entero-colitis.  This  may  antedate  the  zymotic  affection.  In 
other  cases,  entero-colitis  commences  either  with  the  scarlet  fever, 
or  during  its  course.  Diarrhoea  often  occurs  in  connection  with 
the  vomiting,  in  the  first  hours  of  the  fever;  and  it  commonly 
ceases  during  the  first  or  second  day.  Occasionally  it  continues 
with  greater  or  less  severity,  when  it  constitutes  a  serious  comijli- 
cation ;  it  is  in  these  cases  due  to  intestinal  inflammation.  Bron- 
chitis and  pneumonia,  so  common  in  measles,  do  not  often  compli- 
cate scarlet  fever. 

A  not  infrequent  complication  is  articular  rheumatism,  occurring 
when  the  fever  begins  to  decline.  Mild  cases  are  more  liable  to  it 
than  those  having  a  severe  form.  Attention  is  called  to  it  by 
the  complaint  of  the  child  of  pain  or  tenderness  in  the  affected 
joints;  or,  if  he  is  too  young  to  speak,  by  evidences  of  pain  when 
the  joints  are  pressed  or  moved.  There  are  usually  but  little 
swelling  and  redness,  and  there  are  fewer  joints  aftected  than  in 
12 


178  SCARLET    FEVER. 

most  cases  of  acute  primary  rlieumatism.  In  my  practice,  a  com- 
mon seat  of  scarlatinous  rheumatism  lias  been  the  areolar  tissue  of 
the  wrist.  The  inflammation  and  infiltration  are  less  than  in 
primary  acute  rheumatism.  This  complication  is  not,  ordinarily, 
serious;  nor  does  it,  as  a  rule,  materially  retard  convalescence.  A 
physician  of  this  city,  however,  informs  me  of  two  cases  in  which 
cardiac  inflammation  occurred  in  connection  with  the  articular 
affection,  as  it  so  frequentl}^  does  in  idiopathic  rheumatism.  The 
urates  are  not  so  commonly  present  in  the  urine  in  scarlatinous  as 
in  ordinary  acute  rheumatism. 

Serous  inflammation,  especially  that  affecting  the  peritoneum, 
pleura,  or  pericardium,  is  a  common  complication,  independently  of 
the  rheumatic  affection.  It  occurs  during  the  desquamative  period, 
and,  continuing  afterwards,  becomes  a  sequel.  Many  such  cases 
are  fatal.  Pericarditis  may  be  with  difliculty  diagnosticated,  if  it 
is  slight,  and  attended  by  only  a  moderate  amount  of  effusion,  and 
it  is,  doubtless,  often  the  cause  of  death  in  those  who  die  suddenly 
and  unexpectedly  during  or  soon  after  an  attack  of  scarlet  fever. 
Pleuritis  occurring  in  scarlet  fever  is  apt  to  be  suppurative.  In 
1865  I  attended  a  little  girl  in  a  mild  attack  of  the  fever.  When 
it  had  nearly  ceased,  and  the  case  was  about  being  discharged,  she 
was  taken  with  severe  pleurisy  of  the  right  side.  The  pleural 
cavity  was  soon  half  filled  with  liquid,  and  after  a  long  sickness, 
extending  over  two  months,  this  liquid,  mainly  pus,  established  a 
communication  with  a  bronchial  tube,  and  was  expectorated.  She 
immediately  recovered. 

In  the  folloAving  case,  the  records  of  which  are  from  my  note- 
book, pericardial  and  peritoneal  inflammation  occurred  as  a  com- 
plication of  scarlet  fever: — ■ 

Case April  7th,  1860,  C — ,  girl,  five  years  and  ten  months  old,  had 

measles  two  years,  and  hooping-cough  one  year  ago.  With  the  excep- 
tion of  a  slight  cough,  she  has  since  remained  well,  till  the  present 
sickness.  Scarlatina  commenced  April  4th,  and  on  the  5th  the  eruption 
appeared.  Symptoms  severe,  but  regular ;  pulse  158,  full;  surface  hot, 
'  and  covered  with  tlie  eruption;  delirium  at  night;  stomach  irritable; 
constipation.  April  8th  to  10th,  symptoms  about  the  same;  no  delirium, 
however;  pulse  varying  from  124  to  153  per  minute  ;  a  deposit  of  urates 
in  the  urine. 

11th.  To-day,  for  the  first,  has  severe  pain  in  the  epigastrium,  ac- 
companied by  tenderness  on  pressure,  and  moderate  distension  at  this 
point.  The  symptoms  otherwise  are  favorable,  though  pretty  severe ; 
pulse  140;  respiration  moderately  accelerated,  but  the  rhythm  natural; 
respiratory  murmur  distinctl}^  heard  in  all  parts  of  the  chest,  vesicular 
in  character,  and  without  rales.  Has  taken  till  to-day  mainly  diapho- 
retic mixtures;  to-day  pulv.  ipecac,  comp.  gr.  iij,  every  three  or  four 


SEQUELS.  179 

hours,  is  ordered;  a  flaxseed  poultici9  to  be  applied  to  tlic  epigastrium  ; 
diet  nutritious,  with  moderate  use  of  stimulants. 

12th.  Epigastric  pain  still  severe ;  great  tenderness  on  pressure  ;  con- 
siderable distension  at  this  point,  and  percussion  elicits  a  dull  sound; 
passed  a  restless  night ;  when  asked  where  she  feels  pain,  she  points  to 
the  throat  and  epigastric  region;  pulse  130  to  140  per  minute;  rash 
fading;  surface  warm  ;  bowels  somewhat  relaxed;  urine  passed  in  usutd 
quantity-.  The  treatment  by  Dover's  powder  and  poultices  is  continued, 
and  a  leech  is  to-da}^  applied  to  the  epigastrium. 

13th.  Pain  less  severe,  but  considerable  tenderness  on  pressure;  pulse 
about  the  same  as  yesterday ;  has  had  through  her  sickness  a  slight 
cough.     She  talks  rationally,  and  sits  much  of  the  time  in  bed. 

14th.  Continued  in  the  same  state  as  described  in  yesterday's  records, 
till  3  P.  M.  yesterday,  when  she  became  suddenly  worse  ;  her  respiration 
was  short  and  gasping ;  she  spoke,  with  an  effort,  in  a  whisper,  but 
continued  conscious ;  and  her  pulse  was  strong.  Death  occurred  at 
5  P,  M.,  apparently  from  obstructed  respiration.  In  the  last  days  of 
her  sickness  there  was  but  little  pharjaigitis,  and  little  or  no  external 
swelling. 

Autopsy  ticenty-four  hours  after  death. — Body  a  little  emaciated  ;  heart 
large  for  a  child  of  five  years  ;  about  one  ounce  of  turbid  serum  in  the 
pericardium  ;  a  soft  deposit  of  lymph  within  the  pericardial  sac  at  the 
base  of  the  heart,  around  the  origin  of  the  great  vessels  evidence  of 
recent  circumscribed  pericarditis  ;  from  four  to  eight  ounces  of  trans- 
parent serum  in  each  pleural  cavit}' ;  no  fibrin  upon  or  opacity  of  the 
pleural  surfaces ;  mucous  membrane  of  bronchial  tubes  injected  in  streaks, 
and  muco-pus  can  be  pressed  from  them  ;  both  lungs  can  be  readily  in- 
flated, with  the  exception  of  small  portions  of  both  the  lower  lobes, 
which  are  hepatized,  and  can  be  but  partially  inflated ;  liver  enlarged, 
presenting  a  congested  appearance,  and  extending  some  four  inches  be- 
low the  free  border  of  the  ribs ;  upon  its  convex  surface  in  the  epigas- 
trium, corresponding  with  the  seat  of  the  pain,  is  a  white  rough  patch 
of  fibrin  about  one  and  a  half  inches  in  diameter;  kidneys  congested; 
stomach  and  small  intestines  apparently  healthy;  mesenteric  glands 
moderately  enlarged;  mucous  membrane  of  transverse  and  descending 
colon  somewhat  injected  and  thickened,  showing  mild  colitis;  no  ulcera- 
tion noticed ;  brain  not  examined. 

Microscopic  examination  was  made  of  the  blood,  hepatized  portions 
of  lung,  etc.,  but  nothing  of  special  interest  in  this  connection  was 
observed. 

Tliis  case  is  instructive  as  sliowing  the  liability  which  exists  in 
and  after  scarlet  fever  to  inflammations,  and  the  difficulty  of 
diao-nosticatino;  theni  in  certain  cases  on  account  of  their  circum- 
scribed  character. 

Sequelje. — The  complications  described  above  jnay  occur  as 
sequchie,  but  there  is  another  pathological  state  which  may  be 
a  complication,  and  is  a  common  and  serious  sequel.  I  refer  to 
nephritis  with  albuminuria.  This  occasionally  commences  in  scar- 
let fever,  but  usually  not  till  the  disappearance  of  the  rash.  There 
is  sometimes,  during  the  course  of  scarlet  fever,  and  even  subse- 


180  '  SCAELET    FEVER. 

qiientlj,  slight  albnminiiria  due  to  simple  congestion  of  the  kid« 
neys,  but  the  albuminuria  to  which  I  allude,  and  which  requires 
treatment,  is  more  serious.  Its  anatomical  character  is  as  follows  : 
hyperfemia,  and  perceptible  increase  in  volume  of  the  kidneys ; 
proliferation  of  the  renal  epithelial  cells  like  that  of  the  epidermis, 
and  a  granular  deposit  in  them ;  the  escape  of  albumen  from  the 
engorged  capillaries,  and  its  appearance  in  the  urine ;  the  forma- 
tion of  fibrinous  casts  in  the  tubuli  uriniferi,  these  casts  often  con- 
taining more  or  fewer  epithelial  cells  ;  the  escape  of  the  casts  from 
the  kidneys  with  the  urine ;  diminution  of  amount  of  urea  ex- 
creted, and,  therefore,  its  accumulation  in  the  blood ;  and  finally 
rupture  of  the  engorged  capillaries  of  the  kidneys,  and  mingling  of 
the  elements  of  the  blood  with  the  urine. 

The  presence,  therefore,  of  this  renal  aflfection  can  be  readily 
ascertained  by  examining  the  urine.  The  quantity  of  albumen 
which  this  liquid  contains  can  be  aj^proximatively  ascertained  by 
adding  nitric  acid  or  applying  heat.  If  the  quantity  is  small,  simple 
cloudiness  is  produced  ;  if  large,  the  urine  becomes  thick  and  white, 
and  in  extreme  cases  almost  semi-solid  from  coagulation  of  the  albu- 
men. The  character  of  the  urine  can,  however,  be  more  accurately 
ascertained  by  the  microscope  than  by  the  tests  which  have  been 
mentioned,  since  by  it  we  discover  the  fibrinous  casts,  altered  epi- 
thelial cells,  and  blood  corpuscles. 

Nephritis,  with  the  consequent  uraemia,  soon  gives  rise  to  evident 
symptoms.  Serous  eftusion  takes  place  in  consequence  of  the  altered 
state  of  the  blood,  the  most  common  form  of  which  is  anasarca, 
occurring  upon  the  face  and  limbs,  and  sometimes  in  the  areolar 
tissue  of  the  trunk.  Often  the  effusion  occurs  only  in  the  external 
areolar  tissue,  and  the  result  is  then  favorable;  but  in  other  cases  it 
occurs,  and  in  the  order  mentioned  as  regards  frequency,  in  the 
lungs  (oedema  pulmonum),  serous  cavities,  and,  lastly,  in  the  submu- 
cous connective  tissue  of  the  larynx  (oedema  glottidis).  The  internal 
effusion  should  excite  the  gravest  apprehensions,  as  it  is  often  fatal. 
Fortunately,  it  is  in  most  cases  preceded  as  well  as  accompanied 
by  anasarca,  which  is  easily  detected,  so  that  there  is  sufficient 
forewarning.  The  fact  of  an  occasional  exception  to  this  rule 
should  be  borne  in  mind. 

Scarlatinous  nephritis,  with  consequent  uraemia,  is  due  to  the 
direct  effect  of  the  scarlatinous  poison  on  the  kidneys.  I  have 
known  it  occur  in  the  nurse  who  attended  a  child  through  the 
fever,  but  did  not  suffer  from  the  fever  herself.  It  sometimes  occurs 
quite  abruptly,  and  often  when  the  patient  has  been  progressively 


I 


SEQUELJil.  181 

convalescing,  and,  perhaps,  lias  seemed  out  of  danger.  In  most 
cases,  however,  there  are  well-marked  premonitory  symptoms,  as 
fever,  restlessness,  loss  of  appetite.  The  anasarca  is  first  observed 
in  the  face  or  about  the  ankles.  Sometimes  it  remains  inconsider- 
able, but  in  other  cases  it  increases  day  by  day,  more  or  less 
rapidly,  till  the  appearance  of  the  patient  is  much  altered.  In 
marked  cases  of  anasarca  the  features  are  so  bloated  that  their 
natural  expression  is  lost.  The  volume  of  the  trunk  and  legs 
is  augmented,  and,  more  slowly,  that  of  the  arms.  In  the  male 
child  the  penis  and  scrotum  frequently  attain  three  or  four  times 
their  normal  dimensions,  in  consequence  of  serous  infiltration. 

The  duration  of  the  anasarca  or  dropsy  is  very  dift'erent  in  dif- 
ferent cases.  If  the  form  be  oedema  pulmonum,  oedema  glottidis, 
or  intra-cranial  effusion,  deatli  is  speedy.  It  may  occur  even  witliin 
a  day.  Hydrothorax  and  hydropericardium  are  also  ordinarily 
fatal,  though  not  so  speedily  ;  while  in  ascites  the  prognosis  is 
much  more  favorable.  The  duration  of  anasarca  under  the  most 
favorable  circumstances,  unless  it  is  very  slight,  is  commonly  not 
less  than  two  or  three  weeks,  and  is  often  much  longer.  There  is 
another  and  an  important  source  of  danger  apart  from  the  serous 
effusions,  namely,  the  retention  of  urea  in  the  blood.  Convulsions, 
coma,  and  death  may  occur  from  urtemic  poisoning,  as  in  Bright's 
disease.  In  those  cases  there  is  great  and  continued  scantiness  of 
urine,  in  consequence  of  obstruction  in  the  tubuli  uriniferi  from 
fibrinous  casts  and  granular  and  swollen  epithelial  cells.  • 

The  liability  to  this  renal  affection  is  greatly  increased,  and  in 
some  cases  is  mainly  attributable  to  the  close  relationship,  as  re- 
gards their  functions,  which  exists  between  the  skin  and  kidneys. 
A  common  exciting  cause  is  exposure  to  vicissitudes  of  tempera- 
ture or  currents  of  air,  by  which  the  surface  is  chilled,  and  cutane- 
ous transpiration  checked,  at  the  time  when  the  old  epidermis  is 
being  detached.  The  increased  burden  thrown  upon  the  kidneys 
results  in  the  pathological  state  which  has  been  described.  This 
remark  does  not  conflict  with  the  statement  already  made,  that  the 
nephritis  is  due  to  the  direct  effect  of  the  scarlatinous  principle  on 
the  kidneys,  the  disturbance  of  the  function  of  the  skin  merely  in- 
creasing the  functional  activity  of  these  organs  and  rendering  them 
more  susceptible  to  the  disease.  All  who  have  seen  much  of  scarlet 
fever  can  recall  to  mind  cases  in  which  the  patients  had  nearly 
recovered,  when  from  some  needless  exposure  in  the  streets,  or  by 
chilling  of  the  body  in  a  cold  room,  or  open  window,  this  affection 
occurred,  with  perhaps  a  fatal  result.     Elsewhere  I  have  alluded 


182  SCARLET    FEVER. 

to  a  case  in  which  scarlet  fever  was  only  detected  by  this  sequel, 
which  began  when  the  child  was  daily  exposed  in  the  open  air. 
But  many  children  who  have  been  attended  with  the  utmost  care, 
and  who,  through  the  whole  desquamative  period,  are  kept  in  a 
uniform  temperature,  nevertheless  become  affected  with  albumi- 
nuria and  dropsy,  so  that  there  is  sufficient  cause  of  this  sequel  in 
the  state  of  the  child  and  the  nature  of  the  disease  through  which 
he  has  passed,  apart  from  extraneous  influences.  It  is  an  interest- 
ing fact  that  albuminuria  is  more  ajrt  to  occur  after  mild  than  severe 
cases  of  scarlet  fever,  and  observations  show  that  this  difference  in 
liability  to  albuminuria  is  intrinsic ;  in  other  words,  that  it  does 
not  dejDend,  as  some  have  supposed,  on  a  difference  in  the  hygienic 
manao-ement  of  mild  and  severe  scarlatina. 

The  symptoms  in  scarlatinous  nephritis  vary  not  only  according  to 
the  degree  of  the  inflammation,  but  also  according  to  the  amount  and 
seat  of  the  effusion.  I  have  stated  that  it  usually  commences  with 
languor  and  more  or  less  fever.  The  pulse  remains  accelerated,  the 
skin  is  hot  and  dry,  and  the  appetite  poor.  This  affection,  if  slight, 
may  occur  without  appreciable  effusion,  either  in  the  cellular  tissue 
or  the  cavities,  but  ordinarily  in  these  mild  cases  a  little  puffiness 
is  observed  around  the  eyes  or  upon  the  extremities.  In  the 
majority  of  cases  more  extensive  anasarca  results.  The  skin  is 
then  pallid,  distended,  and  pitting  on  pressure.  The  anasarca  does 
not,  in  most  instances,  give  rise  to  any  marked  symptoms.  If 
oedema  glottidis  or  pulmonum  occur,  the  respiration  becomes 
rapidly  more  embarrassed,  till  soon  the  blood  is  no  longer  suffi- 
ciently oxygenated  for  the  purposes  of  life.  The  chief  symptom  in 
hydrothorax  is  accelerated  and  difficult  respiration ;  in  hydroperi- 
cardium  the  symptoms  are  such  as  arise  from  embarrassed  action 
of  the  heart ;  in  ascites  there  are  either  no  marked  symptoms,  or, 
if  the  amount  of  liquid  is  large,  there  may  be  more  or  less  embar- 
rassment of  respiration  from  compression  of  the  lungs. 

Otorrhoea. — Inflammation  of  the  external  ear,  giving  rise  to 
otorrhoea,  is  a  frequent  sequel  of  scarlet  fever.  It  sometimes 
commences  as  a  complication  in  the  last  stages  of  the  fever;  at 
other  times  it  begins  during  convalescence.  It  often  produces  a 
degree  of  deafness,  which,  in  most  instances,  soon  passes  off.  A 
thin,  purulent  discharge  from  the  ear  may  remain  for  months  or 
even  years,  and  hence  the  name  which  designates  this  affection. 
In  exceptional  cases,  internal  otitis  occurs.  This  is  a  more  serious 
sequel ;  it  may  impair  the  hearing  permanently.  There  are  cases 
in  which  not  only  the  drum  of  the  ear  is  destroyed,  but  the  ossicles 


NATURE.  183 

are  detached,  and  lost  through  the  external  ear.  Complete  deaf- 
ness then  results.  I  have  met  one  case,  in  which  hoth  ears  were 
80  injured  by  scarlet  fever  in  infancy,  that  the  child  grew  up  a 
nnite.  The  result  is  sometimes  still  more  serious.  The  inflamma- 
tion may  extend  inwards,  causing  caries  of  the  petrous  portion  of 
the  temporal  bone,  till  it  reaches  the  lateral  or  petrosal  sinuses. 
The  inflammation  then  causes  thickenins:  and  bulo-ino;  of  the 
walls  of  the  sinuses,  and,  consequently,  partial  obstruction  to  the 
circulation,  congestion  in  the  veins  and  sinuses,  the  formation  of 
thrombi,  and  finally  coma  and  death.  Fortunately,  this  melan- 
choly termination  of  scarlatinous  otitis  is  not  frequent. 

Anatomical  Characters. — There  is  some  difiiculty  in  determin- 
ing what  are  the  anatomical  characters  of  scarlet  fever,  since  so 
many  who  die  of  this  disease  have  a  complication,  and  the  lesions 
of  this  are  superadded  to  those  of  the  fever.  The  following,  how- 
ever, are  the  facts  which  have  been  ascertained  in  reference  to 
this  point.  In  many  the  brain,  its  membranes,  and  the  lungs  are 
congested;  often, also,  the  Peyerian,  solitary,  and  mesenteric  glands 
are  enlarged,  and  the  spleen  enlarged  and  softened.  The  liver  and 
kidneys  do  not  present  any  notable  alteration,  though  the  latter 
are  so  often  affected  during  the  period  of  convalescence.  Dr. 
Samuel  Fenwick  {London  Lancet^  J^ily  23,  1864)  has  made  post- 
mortem examinations  in  sixteen  cases  of  scarlet  fever,  and  concludes 
from  them  that  there  is  inflammation  of  the  mucous  membrane  of 
the  stomach  and  intestines  like  that  of  the  skin,  and  that  there  is 
desquamation  of  the  epithelial  cells  from  those  portions  of  the 
digestive  tube  like  that  of  the  epidermis.  I  have  had  opportunity 
of  examining  the  stomach  and  intestines  in  those  who  died  in 
the  eruptive  stage  during  epidemics,  in  the  ITursery  and  Child's 
Hospital,  and  have  never  found  any  unusual  hypersemia  of  the 
gastro-intestinal  surface,  unless  when  gastro-intestinal  inflammation 
had  occurred  as  a  complication.  In  malignant  cases  the  blood  is 
dark,  and  the  heart-clots  soft  and  small ;  in  other  cases  the  color  of 
the  blood  may  be  nearly  normal,  and  the  heart-clots  of  the  usual 
size  and  firmness. 

Mature. — Scarlet  fever  presents  in  a  marked  degree  the  distin- 
guishing features  of  the  contagious  afiections.  It  is  highly  infec- 
tious ;  it  is  also  inoculable.  Stoll,  d'Amboise,  and  others  successfully 
inoculated  with  the  scarlatinous  virus,  using  the  blood,  but  without 
diminishing  the  intensity  of  the  disease.  Whether  scarlatina  ever 
originates  spontaneously  is  uncertain;  but  if  it  do,  such  cases  are 
rare.     It  ordinarily  spreads  through  a  community  by  infection, 


18-i  SCAELET    FEVEE. 

though  the  distance  to  which  it  is  infectious  is  short,  probably  not 
more  than  two  or  three  yards.  Some  consider  the  distance  to  be 
even  less  than  one  yard.  Knowledge  of  this  fact  is  important, 
as  by  isolating  in  a  family  a  child  attacked  by  scarlet  fever,  and 
allowing  no  communication  with  the  nurse,  the  other  children 
often  escape.  A  very  common  mode  of  communication  is  by 
clothing,  so  that  a  third  j^erson  is  the  medium  of  transmission.  I 
have  noticed  that  when  scarlet  fever,  as  well  as  measles,  is  epidemic 
in  this  city,  a  large  proportion  of  the  cases,  nearly  all,  indeed,  of 
the  first  cases,  can  be  traced  to  the  public  schools.  Exposure  occurs 
through  those  children  who  come  from  apartments  where  cases  are 
under  treatment.  Physicians,  and  especially  nurses,  are  sometimes 
the  medium  of  communication.  A  medical  friend  of  mine  went 
directly  from  some  children  with  scarlet  fever,  whom  he  was 
attending,  to  another  family,  where  he  took  a  little  girl  upon  his 
knee.  This  girl  in  a  few  days  became  affected  with  scarlet  fever 
and  died.  The  two  remaining  children  in  the  family  were  then 
attacked,  and  one  died.  Murchison  alludes  to  similar  cases  {London 
Lancet,  August  13,  1864).  In  one  instance  in  my  practice  scarlet 
fever  was  communicated  to  an  infant  by  a  washer- woman  whose 
own  child  had  the  disease,  and  who,  on  reaching  the  house  where  she 
had  been  engaged  to  work,  threw  her  shawl  over  the  cradle  where 
the  infant  was  sleeping.  Six  days  later  the  infant  was  attacked. 
Mason  Good  cites  a  case  where  a  box  of  toys  was  the  medium  of 
communication;  and  it  is  said  that  also  a  letter  has  been.  The 
scarlatinous  virus  may  remain  for  weeks  and  even  months  in 
apartments,  clothing,  or  in  or  upon  the  person  of  one  who  has 
been  affected,  without  any  appreciable  diminution  in  its  effective- 
ness. A  physician  of  this  city,  in  whose  family  scarlet  fever 
occurred,  excluded  a  child  from  the  room  occupied  by  the  patients, 
and  from  the  patients  themselves,  for  a  month  after  the  last  case 
occurred,  and  yet,  although  ^jrecautions  had  been  taken  in  reference 
to  clothes  and  bedding,  this  child  was  taken  with  scarlet  fever  soon 
after  it  was  allowed  to  mingle  with  the  other  children.  The  father 
believes  that  the  exposure  was  through  the  otorrhoea  of  one  of  the 
children.  Observations,  indeed,  appear  fully  to  establish  the  fact 
that  the  discharge  from  the  ear  or  nostrils,  and  the  particles  of 
epidermis  which  have  exfoliated,  may  retain  the  virus  and  be  the 
medium  of  communicating  the  disease  several  weeks  after  the  fever 
has  terminated.  In  a  case  in  my  practice  a  little  girl  returned 
home  six  weeks  after  her  brother  had  scarlet  fever,  and,  within  a 
few  days,  took  the  disease.     A  more  striking  example  occurred 


NATURE.  185 

in  tlic  practice  of  Dr.  Kearney  Rogers,  formerly  a  prominent  and 
much  esteemed  surgeon  of  this  city,  and  was  related  to  me  by  an 
intelligent  friend  of  the  family  since  the  doctor's  death.  Six 
children  in  a  family  had  scarlet  fever.  Three  and  a  half  months 
subsequently  another  child,  living  at  a  distance,  was  allowed  to 
visit  them  in  the  apartments  where  they  had  been  sick.  One  week 
from  that  day  this  child  became  affected  with  the  disease.  Dr. 
Elliotson  states  that  a  patient  with  scarlet  fever  was  admitted  into 
one  of  the  wards  of  St.  Thomas's  hospital,  and,  for  two  years 
subsequently,  young  persons  who  were  admitted  into  this  ward 
wei^e  apt  to  take  the  disease.  Dr.  Richardson  relates  the  case  of  a 
family  of  four  children,  residing  in  the  country.  One  died  of 
malignant  scarlet  fever,  and  the  rest,  who  had  been  removed, 
escaped.  Some  weeks  subsequently  one  of  the  children  returned, 
but  within  twenty-four  hours  took  the  disorder  and  died.  The 
cottage  was  now  thoroughly  cleaned,  whitewashed,  and  the  clothing 
destroyed.  Four  months  then  elapsed,  when  the  third  child  returned 
home,  who  also  took  scarlet  fever  in  a  malignant  form  and  died. 
It  was  believed  that  the  virus  remained  attached  to  the  thatch, 
which  extended  close  to  the  children's  bed.  Other  similar  examples 
might  be  mentioned,  sufficient  to  establish  the  fact  of  the  great 
permanence  of  the  scarlatinous  virus. 

The  period  of  incubation  in  scarlet  fever  varies.  It  is  seen  in 
the  remarkable  example  of  contagion,  given  above,  that  it  was  only 
twenty-four  hours.  Trousseau  also  relates  an  interesting  example 
of  short  incubation.  "  An  English  gentleman  with  his  daughter 
was  returning  from  Pau  to  London,  and  was  joined  at  Paris  by 
another  daughter,  who  came  direct  from  London.  Scarlet  fever 
was  prevalent  in  London,  but  there  was  not  a  cas^  of  it  at  Pau. 
The  second  daughter  was  seized  with  scarlet  fever  in  crossing  the 
channel,  and  joined  her  relatives  in  Paris  seven  or  eight  hours  later. 
She  occupied  the  same  room  in  the  hotel  as  her  sister,  who  was 
also  attacked  within  twenty-four  hours."  The  incubative  period 
is,  however,  seldom  so  short.  It  is  usually  from  three  to  eight 
days.  I  might  cite  several  cases  in  which  this  was  its  duration. 
Some  writers  allude  to  cases  in  which  two,  three,  or  even  four 
weeks  elapsed  from  the  time  of  exposure  to  the  appearance  of  the 
disease.  It  is,  however,  a  question  whether  in  such  cases  there 
may  not  have  been  a  second  and  more  recent  exposure.  Rostan 
alludes  to  cases  in  which  scarlet  fever  was  communicated  by  inocu- 
lation, and  in  which  the  period  of  incubation  was  seven  days. 

Scarlet  fever  occurs  most  frequently  between  the  ages  of  three 


186  SCARLET    FEVER. 

and  ten  years.  It  is  infrequent  under  the  age  of  one  year,  and 
infants  under  the  age  of  three  months  may  be  ^considered  safe  from 
an  attack  of  it,  though  fully  exposed.  Cases  have  been  reported 
of  scarlet  fever  occurring  in  the  foetus,  and  manifesting  itself  by 
the  usual  signs  at  birth.  But  a  clear  diagnosis  in  such  instances 
is  necessarily  difficult,  on  account  of  the  character  of  the  scarla- 
tinous eruption  on  the  one  hand,  and  the  nature  of  the  cutaneous 
circulation  in  the  newly-born  on  the  other.  It  is  probable  that,  in 
the  cases  alluded  to,  there  was  an  error  of  diagnosis.  Certainly  in 
two  instances  I  have  known  women  immediately  after  their  con- 
finement (within  a  week)  take  scarlet  fever,  and  although  they 
communicated  the  disease  to  others,  did  not  to  their  infants. 
Murchison  states  that  twice  he  has  known  women  with  scarlet 
fever  to  be  confined,  and  in  both  instances  the  infants  were  healthy. 

Most  adults  possess  immunity  from  scarlet  fever,  although  not 
protected  by  an  attack  of  it  in  childhood.  Parturient  women, 
however,  are  liable  to  it,  and  there  is  considerable  danger  that  the 
physicians  who  attend  them,  if  at  the  same  time  visiting  cases  of 
scarlet  fever,  may  communicate  the  disease  to  them. 

Scarlet  fever  is  sometimes  sporadic,  but,  as  we  meet  it  in  this 
country,  it  occurs  most  frequently  as  an  epidemic.  The  epidemic^ 
vary  greatly  in  type.  Some  are  mild,  and  attended  by  few  com- 
plications, so  that  the  result  of  treatment  is  eminently  satisfactory. 
In  other  epidemics  the  type  is  malignant,  the  complications  fre- 
quent, and  the  percentage  of  deaths  large.  There  is  sometimes  a 
succession  of  epidemics  of  one  type,  and  then  the  character  of  the 
disease  changes.  This  fact  of  a  variable  type  is  important  as  re- 
gards the  value  of  statistics  relating  to  treatment.  Each  epidemic 
has  its  prevailing  character,  but  when  the  form  is  mild,  there  is 
now  and  then  a  case  of  severity,  and  when  it  is  malignant,  now  and 
then  one  of  unusual  mildness.  The  epidemic  influence  is  some- 
times manifested  in  those  exposfed  to  scarlet  fever  by  the  occurrence 
of  pharyngitis,  and,  as  we  have  seen,  nephritis.  Professor  George  B. 
Wood,  of  Philadelphia,  says  ( Treatise  on  the  Practice  of  Med.) :  "  I 
seldom  attend  cases  of  scarlet  fever  without  having  sore  throat." 

Scarlatina  usually  occurs  but  once  in  the  same  individual,  but  a 
second  attack  after  the  lapse  of  several  years  is  not  uncommon,  and 
there  are  even  eases  on  record  of  a  third  attack.  But  physicians 
sometimes  mistake  roseola  or  erythema  for  scarlet  fever,  and, 
though  afterwards  aware  of  their  mistake,  do  not  correct  their 
diagnosis.  Hence  there  is  a  belief  in  the  community  that  second 
attacks  of  scarlet  fever  are  more  frequent  than  they  really  are. 


DIAGNOSIS.  187 

DiAGTrosTS. — In  the  commencement  of  scarlet  fever,  prior  to  the 
eruption,  there  are  no  symptoms  or  appearances  which  will  enable 
us  to  make  a  positive  diagnosis.  Positive  statement  in  reference 
to  the  nature  of  the  disease  might  better  be  deferred,  for  the  credit 
of  the  physician.  Still,  if  a  child  with  regular  bowels,  and  no 
appreciable  local  disease,  a  few  days  after  exposure  to  scarlet  fever, 
is  suddenly  seized  with  intense  fever,  the  pulse  rising  to  110,  120, 
or  more,  and  the  temperature  to  102°,  103°,  or  105°,  there  is  little 
doubt  that  the  disease  is  scarlet  fever.  The  dias-nosis  is  rendered 
more  certain  if  there  is  vomiting,  and  especially  if,  as  is  often  the 
case,  there  is,  at  this  early  period,  a  blush  of  redness  upon  the  fauces. 

When  the  eruption  has  appeared,  the  nature  of  the  affection  is, 
in  most  cases,  apparent.  Still,  roseola  or  erythema,  due  to  intes- 
tinal derangement  or  other  causes,  has  often,  as  already  stated, 
been  mistaken  for  scarlet  fever.  A  day  or  two  suffices  to  show  the 
error.  In  scarlet  fever  there  is  more  inflammation  of  the  faucial 
and  buccal  surface,  more  continuous  and  persistent  redness  of  the 
skin,  and  greater  intensity  and  persistence  of  symptoms,  than  in 
those  diseases.  Scarlet  fever  is  also  further  distino-uished  from 
them  by  the  papular  elevations  upon  the  tongue,  and  the  minute 
papulae  upon  the  skin.  Besides,  in  scarlet  fever,  except  in  the 
mildest  cases,  there  is  from  the  first  the  aspect  of  serious  sickness, 
which  roseola  and-  erythema  do  not  present. 

Scarlet  fever  and  measles  were  long  considered  identical  by  the 
profession,  and,  though  the  ordinary  forms  of  the  two  diseases  can 
be  readily  distinguished  from  each  other,  there  are  instances  in 
which  the  differential  diagnosis  is  attended  by  some  difficulty. 
Measles  occurring  in  a  robust  child,  with  an  active  cutaneous  cir- 
culation, sometimes  presents  a  continuous  eruj^tion  over  a  consid- 
erable part  of  the  surface,  like  the  eruption  of  scarlet  fever.  But 
the  longer  period  of  invasion,  the  coryza  and  bronchitis,  and  the 
absence  or  slight  degree  of  pharyngitis,  in  connection  with  other 
symptoms,  enable  us  to  distinguish  these  cases  from  scarlatina. 
Moreover,  in  those  cases  of  measles  in  which  there  is  continuous 
redness  of  surface  where  the  circulation  is  most  active,  as  upon  the 
face,  the  characteristic  rubeolous  eruption  is  present  in  other  parts, 
so  that,  with  care  in  examination,  error  of  diagnosis  may  be  avoided. 
Scarlet  fever  and  measles  may  indeed  occur  together,  but  such  a 
complication  is  rare. 

The  greatest  difficulty  of  diagnosis  occurs  in  abnormal  scarlatina, 
especially  when  the  rash  is  partial  and  indistinct.  There  is  apt  to 
be,  in  this  form  of  the  disease,  an  inflammatory  complication,  which 


188  SCAKLET    FEVER. 

causes  witlidra-wal  of  blood  from  tlie  surface,  and  it  is  sometimes 
very  puzzling  to  decide  whether  this  is  a  complication,  or  the  sole 
disease.  The  points  involved  in  diagnosis  are  numerous,  but  they 
are  sometimes  not  sufficient  to  show  the  character  of  the  aiFection. 
Grcnerally,  however,  by  observing  the  clinical  history  from  day  to 
day,  the  diagnosis  is  established.  In  cases  of  doubt  it  is  safest  to 
adopt  such  hygienic  management  as  is  appropriate  to  scarlet  fever'. 

Prognosis. — The  prognosis  depends  on  the  form  of  the  disease, 
whether  mild  or  severe,  the  presence  or  absence  of  complications, 
and  the  strength  of  the  patient.  The  mortality  varies  greatly  in 
different  epidemics.  In  epidemics  of  a  mild  type,  the  mortality  is 
sometimes  not  more  than  one  in  twelve,  and  the  ratio  may  be  less ; 
whereas,  if  a  severe  form  is  prevailing,  not  more  than  one  recovers 
in  every  two,  three,  or  four.  The  mortality  is  greater  in  the  city 
than  country,  in  hospital  than  in  private  practice.  Rilliet  and 
Barthez,  in  hospital  practice,  lost  forty-six  out  of  eighty-seven. 
Scarlatina  is,  of  itself,  less  fatal  than  statistics  would  lead  us  to 
suppose,  since  a  large  proportion  of  those  who  die  in  consequence 
of  it  die  from  complications  or  from  sequelee,  rather  than  from  the 
primary  disease. 

The  symptoms,  in  the  first  days  of  scarlet  fever,  which  indicate 
an  unfavorable  termination,  are  convulsions,  except  at  the  very 
commencement,  great  drowsiness,  with  jactitation,  great  elevation 
of  temperature,  a  rapid  pulse,  duskiness  of  the  eruption,  and  feeble 
capillary  circulation.  At  a  later  period,  particularly  in  the  second 
week,  other  unfavorable  symptoms  may  occur  in  malignant  and 
fatal  cases.  Violent  pharyngeal  inflammation,  with  great  external 
swelling  from  the  adenitis  and  cellulitis,  is  apt  to  be  present  at 
this  stage  of  the  disease.  Severe  inflammation  of  this  character, 
as  indicated  by  the  tumefaction,  greatly  increases  the  danger. 

As  there  are  several  complications  and  sequelae  of  a  dangerous 
character,  and  as  these  are  apt  to  occur  suddenly,  and  often  without 
appreciable  existing  cause,  in  mild  as  well  as  severe  cases,  it  is 
unwise  ever  to  make  an  unconditional  favorable  prognosis.  The 
patient  is  not  to  be  considered  entirely  safe  till  two  or  three  weeks 
have  elapsed  after  the  eruption. 

Some  patients  who  have  passed  through  scarlet  fever,  die  of 
asthenia,  in  consequence  of  the  ansemic  state  which  the  fever  has 
produced.  They  have  not  sufficient  vigor  of  system  to  recover, 
although  no  serious  complication  or  sequel  has  occurred.  In  other 
cases  the  pharyngitis  and  cellulitis,  attended  with  tumefaction, 
rendering  deglutition  painful,  and  keeping  up  the  febrile  movement 


TREATMENT.  189 

after  the  primary  disease  has  run  its  course,  have  much  to  do  in 
producing  a  state  of  exhaustion  and  death.  But  the  mortality  in 
the  desquamative  stage,  and  subsequently,  is  more  frequently  due 
to  the  renal  affection,  which  is  so  common,  than  to  any  other  cause. 
This  affection  gives  rise  to  dropsies,  which  are  fatal,  or  to  ursemic 
convulsions,  and  coma.  Sudden  and  unexpected  deaths  are  not 
uncommon  in  scarlet  fever,  and  it  is  probable  that,  in  many  of 
these  cases,  the  immediate  cause  is  uraemia,  which,  not  having 
produced  any  conspicuous  symptoms  till  near  the  close  of  life,  is 
not  discovered. 

Treatment. — Scarlet  fever,  when  mild,  and  without  complica- 
tion, requires  little  treatment.  A  gentle  cathartic,  like  the  citrate 
of  magnesia,  should  be  given  from  time  to  time,  if  there  is  a 
tendency  to  constipation,  and  a  simple  diaphoretic  mixture  in 
addition,  is  all  that  the  case  requires. 

R.  Spts.  aether,  nitr., 
Syr.  ipecac,  aa  5ij ; 
Syr.  simplic.  3J.     Misce. 
Dose,  one  teaspoonful  every  three  hours  to  a  child  of  three  to  five  years. 

If  there  is  restlessness,  an  occasional  warm  mustard  foot-bath 
will  give  relief;  and  if  there  is  considerable  fever,  as  indicated  by 
flushed  face,  heat  of  head,  cephalalgia,  or  other  nervous  symptoms, 
cool  applications  should  be  made  to  the  head,  and  the  face  and 
forehead  occasionally  bathed  with  cool  water,  bay  rum,  or  other 
cooling  lotion.  The  mildest  cases  indeed  commonly  do  well  with- 
out treatment,  except  hygienic,  though  it  may  be  necessary,  in 
consequence  of  the  impatience  of  the  family,  to  prescribe  a  placebo. 
When  the  fever  has  begun  to  abate,  in  such  cases,  if  the  appetite 
returns,  and  there  is  no  complication,  and  no  symptom  of  feeble- 
ness, there  is  little  for  the  physician  to  do.  But  if,  as  is  sometimes 
the  case,  even  when  the  disease  has  been  mild,  the  appetite  remains 
poor,  and  the  aspect  is  anaemic,  tonics  are  required,  especially 
chalybeates. 

The  majority  of  cases,  however,  demand  more  decided  measures 
than  those  described  above.  We  pass  to  the  consideration  of  cases 
of  moderate  severity,  and  those  of  a  grave  character.  Trousseau 
recommends  cold  affusions  as  an  important  part  of  the  treatment. 
They  should  be  employed  in  the  first  stages  of  sthenic  cases.  They 
are  especially  beneficial,  it  is  stated,  in  those  cases  in  which  nervous 
symptoms  predominate.  The  patient  is  placed  naked  in  a  bathing- 
tub,  and  three  or  four  pails  of  water  are  thrown  over  him,  in  a 
space  of  time  varying  from  a  quarter  of  a  minute  to  one  minute, 


190  SCARLET    FEVER. 

after  which  he  is  covered  with  bedclothes,  without  being  wiped. 
Reaction  immediately  occurs,  often  with  more  or  less  perspiration. 
This  treatment  is  repeated  once  or  twice  daily,  according  to  the 
gravity  of  the  symptoms. 

"  Dr.  Currie,"  says  Trousseau,  "  was  the  first  who  made  use  of 
this  treatment,  and  he  established  its  applicability,  as  a  general 
rule,  in  scarlatina  accompanied  by  grave  nervous  accidents,  such  as 
delirium,  convulsions,  diarrhoea,  excessive  vomiting,  considerable 
exaltation  of  the  heat  of  surface."  Trousseau  believes  that  cold 
allusions  diminish  the  febrile  movement,  and  calm  the  nervous 
excitement,  and  he  further  adds:  "*  -^^  I  have  never  adminis- 
tered it  without  deriving  some  benefit."  Public  opinion  is,  how- 
ever, so  averse  to  such  treatment  of  the  eruptive  fevers,  that  one 
of  less  authority  than  Trousseau  would  scarcely  be  able  to  employ 
it.  The  shock  of  such  treatment  to  a  child  not  sufficiently  old  to 
))e  reasoned  with  must  be  considerable,  and  it  would  seem  question- 
able whether  the  excitement  from  such  a  measure  may  not  increase 
the  liability  to  clonic  convulsions. 

In  the  cases  alluded  to  by  Trousseau,  in  which  there  is  great  heat 
of  surface,  and  nervous  symptoms  predominate,  though  cold  affu- 
sions are  not  used,  there  is  no  doubt  of  the  beneficial  efl:ect  of  cold 
applications  to  the  head,  and  sponging  the  face  and  arms.  This  may 
be  frequently  repeated  if  there  is  great  elevation  of  temperature. 

The  medicinal  treatment  of  scarlet  fever  has  varied  greatly  at 
different  j^eriods,  according  to  the  theory  which  happened  to  pre- 
vail, and  it  is  even  now  far  from  uniform.  Phj'sicians,  however, 
generally  prescribe  sustaining  measures.  If  catalysis  occur,  as  the 
fundamental  pathological  process,  in  scarlet  fever,  and  the  other 
so-called  zymotic  diseases,  and  if  we  possess  safe  anti-catylitic 
medicines,  which  will  arrest  this  process,  these  agents  are  in  all 
cases  required.  But  the  use  of  anti-catylitics  is  still  experimental, 
and  they  are  not,  therefore,  to  be  recommended  in  place  of  remedies 
which  have  been  long  employed,  and  are  knoAvn  to  be  of  real  value. 

Depletion  is  rarely  required  in  scarlet  fever ;  on  the  other  hand, 
sustaining  measures  are  indicated  from  the  first.  Bloodletting, 
formerly  more  or  less  employed  in  the  treatment  of  this  disease, 
is  now  almost  obsolete.  In  no  instance  is  venesection  required. 
In  rare  instances,  in  robust  children,  having  an  active  circulation 
and  a  decidedly  sthenic  form  of  the  disease,  there  might  be  a  con- 
dition in  which  one  or  tw^o  leeches  would  be  serviceable;  as,  for 
example,  leeches  applied  to  the  temple,  if  there  is  evidence  of 
dangerous  cerebral  congestion.     But  in  these  cases  a  sufficiently 


TKEATMENT.  191 

sedative  or  tranquillizing  effect  can,  ordinarily,  ])e  produced  by 
the  application  of  cold  to  the  head,  cold  ablutions  to  the  face  and 
hands,  and  by  an  occasional  warm  general  or  foot  bath.  In  all 
malignant  cases,  measures  which  reduce  the  vital  powers  cannot 
fail  to  be  injurious.  In  those  cases  which  are  properly  designated 
by  that  name,  there  are  often  evidences  of  prostration  from  the 
first,  as  drowsiness,  jactitation,  delirium,  languid  circulation, 
evinced  by  the  dusky  hue  of  the  surface.  These  symptoms  indi- 
cate the  need  of  stimulants. 

In  the  ordinary  as  well  as  severe  forms  of  scarlet  fever,  carbonate 
of  ammonia,  administered  with  a  tonic,  is  one  of  the  best  remedies. 
It  is,  moreover,  recommended  by  the  best  authorities.  It  may  be 
prescribed  at  the  first  visit  of  the  physician,  and  continued  at 
regular  intervals.  It  is  used  as  a  main  remedy  by  many  judicious 
and  skilful  practitioners.  I  ordinarily  prescribe  it  in  combination 
with  citrate  of  iron  and  ammonia. 

R.  Amnion,  carbouat., 

Ferri  et  ammou.  citrat.,  aa  333; 
Syr.  simplic.  gij.     Misce. 

Dose,  one  teaspoonful  every  three  hours  to  a  child  of  five  years. 

The  preparations  of  cinchona  are  also  useful  tonics.  The  reader 
is  referred  to  our  remarks  on  the  use  of  carbolic  acid,  under  the 
head  of  Prophylaxis.  It  promises  to  be  not  only  a  prophylactic, 
but  remedial  agent  of  great  value  in  scarlet  fever. 

An  unpleasant  symptom  in  most  cases,  and  one  which  increases 
greatly  the  restlessness  of  the  patient,  is  itching  of  the  skin.  The 
safest  and  best  remedy  for  this  is  inunction.  Fresh  lard  has 
sometimes  been  employed  for  this  purpose.  It  relieves  the  dry- 
ness, and  in  a  measure  the  heat  of  surface,  and  at  the  same  time 
diminishes  the  itching.  The  odor  from  the  lard  is,  however, 
offensive  after  it  has  been  used  for  a  day  or  two.  An  equally  eflica- 
cious,  more  agreeable,  but  more  costly  substance  for  the  inunction 
is  glycerine,  which  may  be  applied  pure,  or  scented  with  one  of 
the  essential  oils.     Dr.  J.  F.  Meigs  recommends  the  followins:: — 

R.  Glycerinse  5j ; 

Ung.  aq.  rosse  §j.     Misce. 

I  prefer  to  either  of  these  applications  the  employment  of  sweet 
oil  or  glycerine,  to  each  ounce  of  which  about  six  or  eight  drops  of 
carbolic  acid  are  added. 

The  inunction  should  be  made  with  the  palm  of  the  hand,  or  with 
muslin  or  linen.     Those  parts  of  the  surface  which  are  the  seat  of 


192  SCARLET    FEVER. 

itching  sliould  be  frequently  treated  in  this  way,  and  occasionally 
the  application  may  be  made  over  the  entire  surface.  'Not  only 
does  inunction  have  the  local  effect  which  has  been  described,  but 
it  is  stated  to  diminish  sensibly  the  ra^^idity  of  the  pulse  and  the 
general  temperature  of  the  body. 

The  cases  which  require  the  closest  watching  and  the  most  judi- 
cious manag-ement  are  those  of  an  ataxic  character.  These  cases 
are  characterized  by  nervous  symptoms,  as  jactitation,  drowsiness, 
delirium.  There  is  great  heat  of  surface,  while  the  capillary 
circulation  is  sluggish.  Sometimes  the  rash  is  indistinct.  In  such 
cases  a  general  warm  bath  is  useful,  to  which  mustard  is  added  in 
sufficient  quantity  to  cause  some  irritation  of  the  surface.  This 
not  only  quickens  the  capillary  circulation,  producing  a  better 
color  of  the  rash,  or  causing  it  to  appear,  if  its  development  is 
retarded,  but  it  calms  the  nervous  excitement,  and  is  often  instru- 
mental in  preventing  convulsions.  If  convulsions  occur,  which 
are  attended  by  disappearance  of  the  eruption,  the  bath  should  be 
employed  at  once.  In  grave  cases,  in  which  the  rash  is  indistinct, 
some  physicians,  whose  opinions  are  entitled  to  consideration,  em- 
ploy belladonna  in  sufficient  dose  to  cause  an  eruption.  I  am  not 
aware,  however,  that  the  severity  of  scarlet  fever  is  diminished  by 
this  agent,  as  thus  employed,  although  the  disease  is  apparently 
rendered  more  normal  by  its  use,  so  far  as  the  rash  is  concerned. 

The  pharyngitis  demands  attention  in  most  patients.  Various 
modes  of  treating  this  have  been  recommended.  The  application 
of  leeches  to  the  throat,  once  a  common  practice  in  severe  scar- 
latinous pharyngitis,  has  fortunately  fallen  into  disuse.  If  the 
pharyngitis  might  be  diminished  by  leeching,  which  is  doubtful 
for  this  form  of  inflammation,  the  benefit  is  more  than  counter- 
balanced by  the  evil  effect,  as  regards  loss  of  strength,  which 
results  from  depletion.  The  application  to  the  throat  of  a  cloth 
wrung  out  of  cold  water,  or  containing  pounded  ice,  has  been 
recommended;  but  the  continued  wetting  of  the  patient  which 
such  treatment  necessitates,  and  the  danger  from  constant  cold 
applications  of  chilling  the  body  and  causing  retrocession  of  the 
eruption,  would  deter  the  prudent  ^practitioner  from  employing 
such  measures. 

After  making  use  of  various  applications,  I  have  been  led  to 
regard  with  most  favor  the  use  of  a  slice  of  salt  pork,  cut  as  thin 
as  possible,  and  stitched  to  a  single  thickness  of  muslin  or  linen. 
The  pork  should  pass  from  ear  to  ear,  the  cloth  being  tied  or 
pinned  over  the  vertex.     It  is  best  to  sprinkle  salt,  or  salt  and 


TREATMENT.  193 

pulverized  camplior,  upon  tlie  pork,  in  order  to  secure  a  more 
prompt  etfect.  If  the  application  is  properly  made,  the  surface 
usually  begins  to  he  reddened  in  twenty-four  hours,  and,  by  the 
second  day,  an  impetiginous  eruption  appears  upon  the  part  cov- 
ered by  the  pork.  Counter-irritation  gradually  produced  in  this 
manner  causes  little  sufiering.  Patients,  ordinarily,  do  not  com- 
plain of  it  at  all.  This  application  should  he  continued  through 
the  fever,  being  occasionally  left  off  for  a  day  or  two,  as  too  much 
soreness  is  produced,  and  a  linen  cloth  smeared  with  sweet  oil  or 
some  simple  ointment  applied  in  its  place. 

This  simple  external  treatment  diminishes  the  inflammation 
of  the  mucous  membrane  underneath,  and  also  to  a  certain  extent 
that  of  the  connective  tissue,  in  those  severe  cases  complicated 
with  cervical,  cellulitis  so  that  tumefaction  and  suppuration  about 
the  angle  of  the  jaw  are  less  likely  to  occur.  A  well-known  phj^si- 
cian  of  this  city,  who  has  had  ample  experience  in  the  treatment  of 
children's  diseases,  ordinarily  applies  a  small  blister  over  the  most 
prominent  part  of  the  swelling  at  the  earliest  moment,  and  by  the 
vesication  believes  that  he  often  succeeds  in  materially  diminishing 
the  inflammation.  But  counter-irritation  in  the  manner  which  I 
have  advised  has  the  advantage  of  being  less  painful  while  it  is 
equally  effectual,  and  the  irritated  surface  heals  readily.  I  have 
never  known  the  eruj)tion  produced  by  pork  assume  a  gangrenous, 
phagedenic,  or  otherwise  unhealthy  appearance.  This  treatment 
does  not  always  prevent  a  considerable  degree  of  inflammation  and 
tumefaction,  but,  if  properly  employed,  it  does  diminish  more  or 
less  this  local  affection.  If  there  is  external  swelling  which 
counter-irritation  does  not  remove,  and  it  becomes  red  and  painful, 
irritating  applications  are  no  longer  proper.  Emollient  poultices 
are  now  required. 

Mild  cases  of  scarlet  fever  do  not  require  direct  applications  to 
the  inflamed  faucial  surface.     Gargles  of  a  saturated  solution  of 
chlorate  of  potash,  to  which  one  of  the  astringent  preparations  of 
iron  is  added,  or,  better,  carbolic  acid  in  the  proportion  of  about 
six  drops  to  the  ounce,  should  be  employed  by  those  old  enough  to 
use  them,  in  cases  of  moderate  or  severe  pharyngitis.     In  younger 
children,  and  in  all  cases  in  which  the  pharyngeal  symptoms  are 
urgent,  we  cannot  rely  on  gargles,  but  must  make  direct  applica- 
tions to  the  throat  with  a  probang  or  a  large  camel's-hair  pencil.     I 
advise,  in  such  cases,  the  application  every  three  or  four  hours  of 
the  carbolic  acid  and  chlorate  of  potassa,  directing,  also,  the  nos- 
trils to  be  syringed  with  the  same  three  or  four  times  daily : — 
13 


194  SCAELET    FEVER. 

K.  Acid,  carbolic.  5ss; 
Potas.  chlorat.  5iij  ; 
Glycerinfe  §ij ; 
Aquae  §iv.     Misce. 
For  the  throat. 

The  effect  of  carbolic  acid,  in  checking  the  muco-purulent  dis- 
charge and  relieving  the  inflammation  is  often  very  decided.  Occa- 
sionally, in  severe  cases,  I  apply  once  or  twice  daily  in  addition — 

R.  Liq.  ferri  subsulphat.  5j  ; 
Glycerinse  3iij.     Misce. 

There  is  no  application  more  effectual  than  this  in  removing  any 
pseudo-membrane,  and  by  its  powerful  astringent  effect  diminish- 
ing the  turgescence  of  the  inflamed  surface.  Yeast  is  also  useful 
in  many  of  these  cases,  given  in  the  quantity  of  half  a  teaspoonful 
to  a  teaspoonful  several  times  daily.  As  it  is  swallowed  it  touches 
each  part  of  the  throat,  and,  if  no  drink  is  allowed  for  a  few  minutes 
afterwards,  it  produces  a  healthy,  stimulating  eftect  on  the  dis- 
eased surface. 

Sometimes,  in  feeble  children,  viscid  mucus  collects  in  the 
pharynx  and  around  the  aperture  of  the  glottis,  so  as  to  interfere 
with'  inspiration.  In  these  cases  there  is  danger  of  death  from 
apnoea.  Prompt  interference  is  required.  Swabbing  the  throat 
removes  the  mucus,  which  is  attached  to  the  swab,  or  is  expecto- 
rated by  the  forced  cough  which  the  operation  causes.  The  swab- 
bing may  be  performed  by  a  piece  of  whalebone,  bent  at  the  end 
and  wound  with  linen  or  soft  muslin.  I  usually  employ  it  dipped 
in  the  solution  of  carbolic  acid  and  chlorate  of  potash.  I  have 
sometimes  relieved  the  most  urgent  dyspnoea  by  this  means.  An 
accumulation  of  mucus  in  the  pharynx  or  larynx,  so  as  to  require 
mechanical  interference,  is  most  frequent  in  infants. 

The  diet  in  scarlatina  should  be  nutritious,  consisting  of  animal 
broths,  milk  porridge,  and  the  like.  The  patient  will  rarely  take 
solid  food,  except  in  the  mildest  cases.  Those  affected  with  grave 
forms  of  the  disease  require  nutriment  as  regularly,  night  and 
day,  as  in  typhus  and  typhoid  fevers. 

In  mild  cases,  alcoholic  stimulants  are  not  required,  unless  in 
moderate  quantity  towards  the  close  of  the  disease.  In  severe 
cases,  attended  from  the  first  Avitli  great  prostration,  they  are 
needed  throughout  the  entire  course  of  the  fever.  Wine-whey 
or  milk-j^unch. should  be  regularly  administered,  in  quantity  ac- 
cording to  the  age  of  the  child.  The  presence  of  severe  nervous 
symptoms,  as  jactitation  or  delirium,  in  these  asthenic  cases,  should 


TREATMENT.  195 

not  deter  from  its  employment.  Convulsions  and  coma  are,  indeed, 
less  likely  to  occur  if  stimulants  arc  used,  since  the  scarlatinous 
virus  is,  in  a  measure,  counteracted  by  such  agents.  The  apart- 
ment in  which  the  patient  is  treated  should  be  airy,  and  ventilated 
without  exposure  to  currents  of  air.  The  temperature  of  the  room 
should  be  uniform,  about  68°  for  robust  children  with  high  fever, 
about  70°  for  feeble  children.  It  should  be  a  little  more  elevated 
after  the  fever  has  abated,  and  the  desquamative  period  com- 
menced, than  during  the  fever.  The  patient  is,  indeed,  especially 
liable  to  be  affected  by  changes  of  temperature,  and  currents  of  air, 
in  the  two  or  three  weeks  succeeding  scarlet  fever,  and  this  expo- 
sure is  very  apt  to  result  in  inflammations,  such  as  have  been  de- 
scribed. Therefore  great  care  should  be  exercised  in  reference  to 
the  hygienic  management  of  the  patient  during  convalescence. 
In  stormy  weather  he  should  be  kept  in-door  for  a  month  or  six 
weeks. 

The  nephritic  affection  which  is  so  common  a  sequel  of  scarlet 
fever  is  often  more  dangerous  than  the  primary  disease  itself.  A 
clear  appreciation  of  its  therapeutic  indications  is  important,  since 
by  judicious  treatment  many  recover  whose  lives  would  inevitably 
be  sacrificed  by  improper  measures.  As  there  is  in  these  cases 
active  hypertemia  of  the  kidneys,  having  in  most  cases  an  inflam- 
matory character,  diuretics  which  stimulate  these  organs  should 
not  ordinarily  be  given,  at  least  till  this  pathological  state  has,  in 
a  measure,  abated.  As  the  eliminative  functions  of  the  skin  and 
of  the  intestinal  mucous  surface  are  to  a  considerable  extent  vica- 
rious with  that  of  the  kidneys,  diaphoretic  and  purgative  remedies 
are  required.  By  free  diaphoresis,  the  ill  eftect  of  arrested  or 
diminished  renal  secretion  is,  for  a  time,  averted.  Treatment  to 
produce  diaphoresis  should  vary  somewhat  in  different  cases.  It 
should  in  most  patients  be  commenced  by  the  use  of  a  warm  general 
or  foot  bath,  and  the  patient  then  be  covered  in  bed.  If  free  per- 
spiration is  not  produced,  it  may  be  promoted  by  placing  against 
the  patient  one  or  more  bottles  of  hot  water,  surrounded  by  a  wet 
cloth.  The  steam  arising  from  this,  and  enveloping  the  body  and 
limbs,  produces  a  prompt  sudorific  eftect.  There  is  in  use  in  this 
city,  in  the  treatment  of  these  and  similar  cases  requiring  diapho- 
resis, a  convenient  apparatus  for  generating  steam.  It  consists  of 
a  cylinder  pierced  with  holes  for  the  admission  of  air,  and  con- 
taining a  spirit-lamp  over  which  is  a  pan  or  pail  holding  a  little 
water.  The  patient,  nearly  denuded,  is  placed  in  a  chair,  with  the 
apparatus  by  his  side,  and  is  covered  with  a  blanket  so  that  the 


196  SCARLET    FEVER. 

steam  surronuds  the  body.  This  gives  rise  to  free  perspiration, 
which  continues  after  the  patient  is  phiced  in  bed.  This  treatment 
may  be  repeated  each  day,  if  the  patient  require  it,  while  diapho- 
retics or  cathartics  are  given. 

The  diaphoretics  which  are  most  serviceable  in  this  aifection  are 
the  acetates  of  ammonia  and  potassa,  the  bitartrate  and  citrate  of 
potassa.  Spiritus  fetheris  nitrici,  combined  with  either  of  these, 
increases  the  effect,  if  the  surface  is  warm,  especially  if  there  is 
already  diaphoresis  from  the  bath  or  steam.  Spiritus  Mindereri 
may  be  given  to  a  child  of  five  years,  in  doses  of  two  teaspoonfuls 
every  two  or  three  hours,  either  alone,  or  in  combination  with  sweet 
spirits  of  nitre,  as  in  the  following  formula : — 

R.  Spts.  fetlier.  nitrici  5SS  ; 

Liq.  ammou.  acetat.  5iv.     Misce. 

The  acetate  of  potash  is  a  more  agreeable  medicine,  and  it  is 
generally  quite  as  effectual.  It  should  be  given,  dissolved  in  water 
or  syrup,  in  doses  of  about  one  grain  for  each  year  of  the  child's 
age.  "Wliatever  diaphoretic  is  used,  has  more  effect,  as  has  already 
been  stated,  if  given  in  connection  with  the  external  measures 
designed  to  produce  diaphoresis,  which  have  been  described  above. 
If  perspiration  is  not  produced,  the  action  of  the  medicine  is  proba- 
blv  on  the  kidnevs ;  and  if  diuresis  do  not  result,  there  is  danger 
that  the  hyperssmia  of  the  kidneys  will  be  increased.  In  such  cases 
diaphoretics  should  be  omitted,  and  cathartic  medicines  given  in 
place ;  or,  if  there  is  much  exhaustion,  it  is  sometimes  better  to 
give  no  eliminative  medicine,  and  to  treat  the  renal  affection  mainly 
by  local  and  external  measures.  1 

In  robust  children  suffering  from  scarlatinous  ura?mia  and  serous 
effusions,  no  medicines  afford  so  much  relief  in  the  commencement 
as  cathartics  of  a  hvdras-oo-ue  nature.  A  mixture  of  ialap  and 
cream  of  tartar,  pulvis  jalapae  compositus  of  the  pharmacopoeia, 
meets  the  indication.  Even  in  children  somewhat  reduced,  medi- 
cines of  this  nature  are  often  required.  Cathartics  are  more  certain 
in  their  effects  than  either  diaphoretics  or  diuretics,  and  therefore 
they  should  be  given  in  urgent  cases  in  which  it  is  necessary  to 
remove  the  urea  or  serum  as  speedily  as  possible.  An  excellent 
prescription  in  many  of  these  cases,  and  one  from  which  I  have 
obtained  a  good  result,  is  the  following: — 

E.  Podophyllin  gr.  j  ; 

Sacch.  alb.  9j.     Misce. 
Divid.  in  chart,  no.  viii-xii. 
Dose,  one  po\vder,  according  to  circumstances. 


TREATMENT.  197 

"When  cathartic  or  laxative  agents  have  been  used  two  or  three 
days,  the  kidneys,  being  less  congested  in  consequence  of  the  diver- 
sion that  has  occurred,  often  begin  to  excrete  more  freely.  Sub- 
sequently to  the  employment  of  medicines  of  this  kind,  or  in  con- 
nection with  them,  diaphoretics  are  in  most  cases  required.  The 
physician's  experience,  and  his  discrimination  in  reference  to  the 
condition  of  the  patient,  will  guide  him  in  the  selection  of  proper 
remedies  to  meet  the  indications. 

In  a  large  proportion  of  cases,  when  this  renal  aifection  has 
continued  one,  two,  or  three  weeks,  the  treatment  which  has  been 
recommended  above  is  no  longer  appropriate.  There  may  be  more 
or  less  anasarca  and  albuminuria,  but  the  patient  is  ansemic,  and 
evidently  in  need  of  sustaining  measures,  while  there  are  no  symp- 
toms which  indicate  immediate  danger  from  retention  of  urea  or 
the  excess  of  liquid  in  the  system.  In  these  cases  the  tincture  of 
the  chloride  of  iron  is  a  most  useful  medicine.  While  it  serves  as 
a  tonic,  it  seems  also  to  have  a  diuretic  effect.  To  a  child  of  five 
years  it  should  be  given  in  doses  of  five  drops,  every  three  or  four 
hours. 

If  the  patient  is  decidedly  anfemic  and  feeble  when  the  renal 
affection  commences,  and  the  symptoms  are  not  urgent,  it  is  best 
not  to  administer  diaphoretics  and  cathartics,  or  to  administer 
them  sparingly,  and  to  commence  early  with  sustaining  remedies. 
Cases  like  the  following  from  my  note-book  are  not  infrequent.  A 
little  boy,  pale  and  scrofulous,  began  to  have  anasarca,  after  scarlet 
fever,  chiefly  of  the  scrotum,  and  accompanied  by  a  moderate  de- 
gree of  ascites.  The  urine,  which  was  passed  in  nearly  the  normal 
quantity,  contained  albumen.  This  patient  gradually  and  fully 
recovered,  with  no  treatment  except  the  use  of  an  oil-silk  jacket 
over  the  kidneys  and  abdomen,  to  promote  diaphoresis,  and  the  use 
of  iron.  Such  a  case  actively  treated  by  eliminatives  would,  proba- 
bly, have  proved  fatal.  Uniform  treatment  for  scarlatinous  nephri- 
tis is  therefore  injudicious  ;  considerable  variation  in  measures  is 
demanded,  according  to  the  state  of  the  patients. 

The  otorrhoea  of  scarlet  fever  should  not  be  neglected.  It  is  apt 
to  continue  for  months  unless  treated,  and  the  hearing  may  become 
permanently  impaired.  There  is  danger,  indeed,  that  the  inflam- 
mation may  extend  inwards,  with  a  most  disastrous  result.  For 
this  ailment  there  is,  in  my  opinion,  no  remedy  so  useful  as  the 
following,  which  should  be  either  dropped  or  syringed  into  the 
ear  three  times  daily : — 


198  SCARLET    FEVER. 

^.  Acid,  carbolic,  o^s-j  ; 
Glycerinre  ^ij  ; 
Aquse  ^iv.     Misce. 

It  is  also  very  beneficial  when  the  otorrhoea  occurs  from  scrofula 
or  other  cause.  When  the  remedial  agents  required  for  the  fever 
are  discontinued,  and  the  otorrhoea  persists,  cod-liver  oil  and  the 
syrup  of  the  iodide  of  iron,  given  in  appropriate  doses,  will  often 
be  found  useful,  not  only  for  the  general  health,  but  the  otorrhoea. 
{See  Lond.  Lancet,  Dec.  3,  1870.) 

It  is  evident,  from  what  has  been  said,  that  every  possible  pre- 
caution should  be  taken  to  prevent  the  patient's  catching  cold 
during  the  period  of  convalescence.  He  should  not  be  allowed  to 
go  in  the  open  air  in  unpropitious  weather  till  a  month  after  the 
fever.  An  oil-silk  protection  of  the  body,  worn  from  the  time 
that  the  febrile  symptoms  begin  to  decline,  and  covering  the  lumbar 
region,  diminishes,  in  my  opinion,  the  liability  to  nephritis  and 
uraemia. 

Prophylaxis. — Since  the  period  of  Jenner's  discovery  of  the  pro- 
phylactic power  of  vaccination,  as  regards  smallpox,  the  attention 
of  the  profession  has  been  frequently  directed  to  the  prevention  of 
scarlet  fever.  A  medicine  has  been  sought  which  would  antago- 
nize and  mollify,  if  not  entirely  prevent,  the  disease.  Of  late  years 
it  has  been  claimed  that  belladonna,  given  during  the  period  of 
exposure,  and  subsequently,  is  a  preventive.  The  first  employment 
of  this  agent  for  such  a  purpose  was  based  entirely  on  theoretical 
grounds,  it  being  presumed  that,  as  it  produces  an  eruption  of  the 
skin  and  dryness  of  the  throat,  like  those  of  scarlet  fever,  it  is  there- 
fore antidotal.  Wli ether  or  not  belladonna  does  have  such  an  effect 
can  only  be  determined  by  experience,  and  latterly,  as  observations 
accumulate,  the  number  does  not  seem  to  increase  of  those  who  be- 
lieve in  its  prophylactic  power.  Still,  there  is  difference  of  opinion 
among  good  observers.  The  ditficulty  of  determining  positively 
the  matter  of  prophylaxis  is  apparent  when  we  consider  that  many 
children  who  are  exposed  to  scarlet  fever  do  not  take  it,  although 
nothing  is  done  for  the  purpose  of  prevention.  Burnett  made  use 
of  the  following  prescription  as  a  preventive : — 

I^.  Ext.  bellad.  gr.  j ; 

Aq.  canella;  gij.     Misce. 

Two  or  three  drops  were  given  morning  and  evening  to  a  child 
of  one  year,  and  one  drop  more  for  every  year  for  children  of  a 


TREATMENT.  199 

more  advanced  age.  He  administered  it  to  120  infants,  of  whom 
only  five  contracted  the  disease.  Schcnck,  lialf  a  century  since, 
stated  that,  in  the  course  of  an  epidemic,  out  of  525  persons  wlio 
took  belladonna  only  three  contracted  the  disease.  M.  Biett,  whose 
observations  were  made  during  the  epidemic  prevalence  of  scarlet 
fever  in  Switzerland,  states  that  those  to  whom  belladoima  was 
given  usually  escaped.  On  the  other  hand,  Lchmann  and  Wagner 
may  be  mentioned  among  others  on  the  continent,  who  believe 
that  they  have  derived  no  benefit  from  the  use  of  this  medicine. 
These  physicians  have  seen  one-fourth  to  one-third  of  those  to 
whom  belladonna  had  been  given  take  scarlet  fever.  In  this 
country,  observers  differ  in  their  estimate  of  the  preventive  effect 
of  belladonna.  Dr.  Irwin,  of  South  Carolina,  as  quoted  by  Dr. 
Condie,  gave  it  to  250  children,  and  less  than  half  a  dozen  took 
the  affection.  He  employed  a  solution  of  three  grains  of  the  ex- 
tract in  an  ounce  of  cinnamon-water,  giving  two  or  three  drops  to 
a  child  under  the  age  of  one  year,  and  one  additional  drop  for  each 
year.  Dr.  Condie  himself,  however,  has  had  a  different  experience. 
He  has  prescribed  belladonna,  "  but,  although  redness  and  dryness 
of  the  throat,  and  a  diffuse  scarlet  efflorescence,  were  produced  in 
the  majority  of  cases,  we  never,"  says  he,  "  found  it  in  any  to  exert 
the  slightest  influence  in  mitigating  the  character  or  preventing 
the  occurrence  of  scarlatina.  The  experiments  were  made  during 
the  prevalence  of  the  disease,  and  in  numerous  instances  the  sub- 
jects of  them  were  attacked.  In  one  case  the  efilorescence  was 
kept  up  by  the  use  of  belladonna  forty-eight  hours.  In  a  week 
afterwards  this  individual  took  the  disease  in  its  most  violent  form, 
and  died  on  the  fourth  day."  My  observations  in  reference  to  this 
use  of  belladonna  are  few,  and  they  are  not  at  all  favorable  to  its 
emi^loyment.  I  have  known  scarlet  fever  occur,  without  appa- 
rently any  modification,  though  belladonna  was  administered  daily. 
Those  who  have  made  trial  of  this  medicine  have  administered  it 
in  very  different  doses.  Hahnemann  employed  it  in  so  small  a 
dose,  that  it  would  seem,  a  jyriori,  that  it  could  have  had  no  effect. 
Hufeland  employed  the  following  formula : — 

]^.  Ext.  bellad.  gr.  iij  ; 
Alcohol  ^j  ; 
Aq.  destillat.  §ss.     Misce. 

Dose,  one  drop  morning  and  evening  for  each  year  of  the  child's  age. 

So  small  a  dose  would  certainly  do  no  harm,  so  that  the  medicine 
might  be  safely  tried.     Still,  if  belladonna  is  at  all  a  prophylactic, 


200  SCAKLET    FEVER. 

it  is  reasonable  to  suppose  that  a  larger  dose  would  be  more  de- 
cidedly so. 

The  great  importance  of  the  prophylaxis  of  scarlet  fever  has 
induced  me  to  state  what  is  known  of  the  effect  of  belladonna 
employed  for  this  purpose.  I  am,  however,  strongly  of  opinion 
that  by  far  the  most  reliable  prophylactic,  of  which  we  have  any 
knowledge,  is  carbolic  acid.  Our  experience  in  Il^ew  York  city,  in 
reference  to  the  employment  of  this  agent  as  a  means  of  prevention, 
has  not  been  sufficient  to  enable  us  to  make  a  positive  statement, 
but  it  has  been  largely  employed  by  the  'New  York  physicians 
under  the  direction  of  the  Health  Board,  in  the  apartments  of  those 
sick  with  infectious  diseases,  and  the  result,  as  regards  at  least 
scarlet  fever,  has  been  highly  satisfactory.  The  Health  Board 
employ  largely  carbolic  acid,  but  other  disinfectants  in  addition  to 
it.  (Appendix  B.)  The  impure  carbolic  acid  is  preferable  to  the 
purified.  Old  rags  soaked  with  it  may  be  suspended  in  the  room, 
or  it  may  be  sprinkled  in  the  corners  of  the  room,  or  placed  on 
plates  two  or  three  times  daily  with  water  added.  A  positive 
statement  in  regard  to  the  effect  in  a  matter  of  such  importance 
should  be  based  on  accurate  and  sufficient  statistics,  but  it  appears 
to  me,  from  cases  which  I  have  observed,  that  the  acid  thus  em- 
ployed not  only  destroys  in  great  part  the  infectiousness  of  scarlet 
fever,  but  also  renders  the  disease  milder  in  patients  who  constantly 
inhale  its  vapor  during  their  sickness.  I  have  been  creditably  in- 
formed that  certain  at  least  of  the  Sanitary  Inspectors  of  the  Health 
Board  of  Xew  York,  whose  opportunities  for  observation  are  ample, 
entertain  similar  views.  I  take  pleasure  in  referring  the  reader  to 
the  opinions  in  reference  to  the  prevention  of  scarlatina  of  a  British 
practitioner,  of  candor  and  great  experience,  who  is  favorably 
known  to  the  profession  on  both  continents.  For  a  knowledge  of 
the  views  of  this  gentleman  I  am  indebted  to  Dr.  Elisha  Harris, 
the  well-known  sanitarian  of  this  city.     (Appendix  B.) 


STAGE    OF    INVASION.  201 


CHAPTER  III. 

VARIOLA  — VARIOLOID. 

Vakiola,  or  smallpox,  is  a  specific  febrile  affection,  accompanied 
by  a  vesiculo-pustular  eruption  of  the  skin.  Since  the  discovery  of 
the  protective  power  of  vaccination,  it  has  been  shorn  of  much  of 
its  terror,  but  it  is  still  the  most  loathsome  and  most  dreaded  of  all 
the  fevers.  Two  forms  of  this  disease  are  recognized,  depending 
on  the  fact  whether  there  has  been  previous  vaccination.  If  the 
patient  has  been  vaccinated  at  some  period  in  his  life,  the  disease, 
which  is  rendered  milder  in  consequence,  is  designated  varioloid. 
If  there  has  been  no  vaccination,  it  is  called  variola  or  smallpox. 
Both  forms  are  identical  in  nature,  the  one  communicating  the 
other :  they  differ  only  in  gravity. 

Smallpox  presents  four  stages:  the  initial,  or  that  of  invasion; 
the  eruptive;  that  of  desiccation;  and, lastly, that  of  desquamation. 
It  is  called  discrete  when  the  pustules  remain  separated  from  each 
other;  confluent  when  they  unite.  This  division  is  made  accord- 
ing to  the  character  of  the  eruption  upon  the  face  and  hands. 
There  are  parts  of  the  surface,  as  the  abdomen,  where  the  pustules 
are  always  discrete,  even  in  the  confluent  form. 

Incubative  Period. — During  the  last  half  of  the  last  century 
inoculation  with  variolous  matter  was  extensively  practised  in 
Great  Britain  and  on  the  Continent,  as  it  was  found  that  smallpox 
thus  communicated  was  milder  than  when  received  by  infection. 
This  operation  enabled  physicians  to  determine  the  period  of  incu- 
bation, which  was  found  to  be  from  eight  to  eleven  days.  When 
variola  is  communicated  by  infection,  the  incubative  period  is  some- 
what longer,  namely,  from  twelve  to  fourteen  days. 

Stage  of  Invasion. — -Smallpox  begins  abruptly  with  chilliness. 
In  children  of  an  advanced  age,  there  is  often,  as  in  the  adult,  a 
distinct  chill.  This  is  followed  by  fever,  and  such  symptoms  as 
usually  accompany  febrile  movement,  namely,  lassitude,  anorexia, 
and  thirst.  There  are,  in  addition,  symptoms  which,  though  not 
peculiar  to  smallpox,  are  so  marked  in  the  commencement  of  this 
disease,  that  they  possess  considerable  diagnostic   value.     These 


202  VAEIOLA. 

symptoms  pertain  to  the  nervous  system.  There  are  in  most  cases 
of  varioloid  as  well  as  variola,  in  the  initial  stage,  severe  frontal 
headache,  pain  in  the  small  of  the  back,  and  great  drowsiness, 
sometimes  with  delirium.  In  many  children  convulsions  occur, 
preceded  and  followed  by  a  degree  of  stupor  which  is  almost  as 
profound  as  coma.  Trousseau  suggests  the  name  rachialgia  for  the 
pain  in  the  back,  as  he  believes  that  it  is  located  in  or  around  the 
spinal  cord.  This  belief  is  based  on  the  fact,  which  he,  as  well  as 
other  observers,  has  noticed,  that  there  is  sometimes  in  connection 
with  this  symptom  an  incomplete  paraplegia,  indicated  by  numb- 
ness of  the  legs,  or  even  inability  to  use  them,  and  sometimes  more 
or  less  paralysis  of  the  bladder.  These  para];»legic  symptoms  pass 
off  in  a  few  days.  Vomiting  is  also  a  common  symptom  in  this  stage, 
and  one  also  of  diagnostic  value.  It  occurs  at  short  intervals  for 
twenty-four  to  thirty-six  hours.  The  same  symptom  is  common 
in  scarlet  fever,  and  not  infrequent  in  measles,  but  in  both  these 
afiections  irritability  of  stomach  is  much  less  persistent  than  in 
smallpox ;  vomiting  does  not  occur  in  normal  rubeolous  and  scar- 
latinous cases  more  than  once  or  twice. 

The  tongue  is  covered  with  a  moist  fur.  If  the  disease  is  to  be 
discrete,  constipation  is  commonly  present  in  the  stage  of  inva- 
sion ;  if  confluent,  diarrhoea  is  a  common  symptom,  continuing 
till  the  fourth  or  fifth  day,  or  even  longer.  Roseola  or  erythema 
sometimes  occurs  in  this  stage,  and  this  may  lead  to  error  of  diag- 
nosis, the  disease  being  mistaken  for  one  of  these  cutaneous  affec- 
tions, or  even  for  scarlet  fever.  The  symptoms  in  the  stage  of 
invasion  are  usually  more  violent  in  confluent  than  in  discrete 
variola,  but  there  are  exceptions. 

Stage  of  Eruption. — The  eruption  commences  about  the  third 
day,  earlier  in  some  cases,  later  in  others.  The  average  duration, 
therefore,  of  the  first  stage  is  somewhat  shorter  than  in  measles, 
but  considerably  longer  than  in  scarlet  fever.  Sydenham  has 
stated,  and  observations  show  the  truth  of  the  remark,  that  the 
shorter  the  first  stage,  the  more  severe  the  disease  will  prove  to  be; 
and,  conversely,  the  longer  the  period,  the  milder  will  be  its  form. 
Therefore,  if  the  eruption  begins  on  the  second  day,  it  will,  as  a 
rule,  be  confluent ;  if  not  till  the  fifth  or  sixth  day,  it  will  be  scanty, 
and  the  disease  lio-ht. 

The  eruption  commences  in  minute  red  spots,  somewhat  like 
those  of  lichen,  which  gradually  enlarge.  It  is  first  observed 
around  the  lips  and  upon  the  neck,  then  upon  the  face,  scalp,  upper 
part  of  chest,  arms,  and  finally  upon  the  lower  part  of  the  chest,  the 


STAGE    OF    ERUPTION.  203 

abdomen,  and  legs.  It  is  sometimes,  especially  in  young  children, 
first  observed  in  the  folds  of  the  skin,  as  about  the  genitals  or  in 
the  groin.  If  the  cuticle  is  irritated,  as  by  a  sinapism,  the  erup- 
tion often  appears  first  upon  this  part  of  the  surface,  and  in  greater 
abundance  than  elsewhere.  The  eruption  commencing  in  a  minute 
reddish  point,  as  stated  above,  rapidly  enlarges,  and  soon  its  cen_ 
tral  part  begins  to  be  indurated  and  raised.  It  feels  round  and 
hard  to  the  finger,  is  tender,  and  its  diameter  does  not  ordinarily 
exceed  two  lines.  This  is  the  papular  stage.  The  papulae  increase, 
and  become  more  elevated,  and  in  twenty -four  to  forty-eight  hours 
from  the  commencement  of  the  eruptive  stage  they  become  vesicu- 
lar. On  the  fifth  day  of  the  eruption,  or  eighth  of  the  disease, 
the  vesicle  has  attained  its  full  size.  Its  diameter  is  then  about 
one-fourth  of  an  inch,  and  its  elevation  is  two  or  three  lines.  Its 
base  is  circular  and  indurated,  and  it  is  surrounded  by  a  narrow 
zone  of  inflammation,  indicated  by  redness  and  tenderness  of  the 
skin.  The  pock  commonly,  as  it  passes  from  the  papular  to  the 
vesicular  stage,  loses  its  acuminate  form,  and  becomes  depressed  in 
the  centre,  but  in  most  cases,  mixed  with  the  umbilicated  vesicles, 
are  some  which  remain  acuminate. 

In  proportion  as  the  eruption  becomes  developed  in  discrete 
variola,  and  in  varioloid,  the  symptoms  w^iich  accompanied  the 
stage  of  invasion  abate;  the  fever,  headache,  pain  in  the  back, 
and  thirst  cease,  and  the  appetite  returns.  In  the  confluent  form, 
the  febrile  action  continues  with  little  abatement. 

Simultaneously  with  the  eruption  upon  the  skin,  an  eruption 
also  occurs  upon  the  buccal  and  faucial  surface,  and  often  upon 
that  of  the  air-passages.  It  occurs  sometimes,  also,  upon  the  con- 
junctiva, producing  dangerous  ophthalmia,  and  even  ulceration, 
with  loss  of  sight;  and  upon  the  mucous  surface  of  the  genital 
organs.  The  form  which  it  presents  upon  mucous  surfaces  is  some- 
what different  from  that  upon  the  skin.  There  is  at  first  a  deposit 
of  fibrin,  producing  a  small,  round,  grayish  spot  at  the  point  of 
eruption — firm,  slightly  elevated,  and  covered,  if  not  by  the  entire 
mucous  membrane,  at  least  by  its  epithelial  layer.  Ulceration 
soon  occurs,  as  in  ulcerous  stomatitis,  and  if  the  patient  live,  the 
repai'ative  process  succeeds,  as  in  simple  ulcers.  The  eruption  upon 
mucous  surfixces  increases  considerably  the  suffering  of  the  patient, 
in  consequence  of  the  tenderness  of  the  ulcers ;  and  if  its  seat  be 
the  surface  of  the  larynx  or  trachea,  it  may  be  the  immediate 
cause  of  death,  especially  in  young  children,  by  obstructing  respi- 
ration. 


204:  VARIOLA. 

The  cutaneous  eruption  has  been  traced  to  the  vesicular  stage. 
On  or  about  the  fifth  day  of  the  eruptive  period,  or  eightli  of  small- 
pox, the  vesicles  gradually  change  their  character,  their  contents 
becoming  thicker  and  turbid.  At  the  same  time  they  increase 
somewhat  in  size,  and  the  central  depression  disappears.  This  is 
designated  the  stage  of  maturation,  or  of  suppuration,  though  it  is 
known  that  the  turbidity  is  due  chiefly  to  another  substance  than 
pus.  The  pock  having  undergone  these  changes,  is  termed  the 
pustule. 

In  discrete  variola,  and  in  varioloid,  the  fever  returns  during  the 
pustular  stage ;  or,  if  the  form  of  the  disease  is  confluent,  and  the 
fever  has  continued,  it  now  becomes  more  intense.  The  return  of 
fever,  or  its  increase,  is  denoted  by  increased  frequency  of  pulse, 
elevation  of  temperature,  dryness  of  skin,  anorexia,  and  thirst. 
A  tendency  to  constipation  remains  throughout  the  disease  in  vario- 
loid and  discrete  variola;  in  the  confluent  form,  diarrhoea  more 
frequently  occurs,  which,  if  it  continue,  is  an  unfavorable  prognos- 
tic sign. 

Other  changes  occur.  The  pustules  increase  somewhat  in  size, 
and  become  more  globular.  Some  of  them,  when  most  distended, 
break  through  friction  of  the  clothes,  or  scratching  of  the  child, 
and  their  contents  escaping,  add  to  the  loathsomeness  of  the  dis- 
ease. There  is  in  the  pustular  stage  more  or  less  redness  of  the 
surface  between  the  eruptions,  and,  except  in  the  mildest  cases, 
there  is  tumefaction  from  subcutaneous  infiltration.  In  the  con- 
fluent form,  at  this  period,  the  features  are  often  so  swollen  that 
the  friends  would  not  recognize  the  patient.  The  eyelids  may  be 
so  cedematous  that  the  eyes  are  for  a  time  concealed  from  view. 
This  oedema  of  the  surface  is  not  altogether  absent  in  the  vesicular 
stage,  but  it  increases  during  the  time  of  maturation,  after  which 
it  subsides. 

Stage  of  Desiccation. — This  immediately  succeeds  the  full  de- 
velopment of  the  pustules.  The  liquid  portion  of  the  contents  of 
the  pustules,  which  are  broken,  evaporates,  leaving  a  crust.  If 
there  is  no  rupture,  the  liquid  is  absorbed,  and  a  scab  results,  which, 
though  smaller,  preserves  in  a  measure  the  form  of  the  pustule. 
While  the  pustule  desiccates,  the  surrounding  inflammation  rapidly 
abates.  The  crusts  occur  first  upon  the  face,  and  on  other  parts  in 
the  order  in  which  the  eruption  appeared.  The  odor  from  the  pa- 
tient, at  this  time,  is  peculiar.  In  the  confluent  form,  especially, 
it  is  very  oftensive,  and  can  be  noticed  at  a  distance  from  the  bed- 
side.    Rilliet  and  Barthez  call  it  nauseous  and  fetid.     As  desicca- 


STAGE    OF    DESICCATION.  205 

tion  progresses,  the  symptoms,  local  and  general,  abate.  The  pnlse 
and  temperature,  if  the  case  is  favorable,  return  to  their  normal 
standard.  The  cough,  hoarseness,  and  thirst  disappear,  while  the 
appetite  returns;  the  sleep  is  more  tranquil,  and  the  functions, 
generally,  are  more  regularly  performed. 

The  last  stage  is  that  of  desquamation;  it  commences  between  the 
eleventh  and  sixteenth  days.  The  scabs,  which  present  a  dark  or 
brownish  appearance,  are  successively  detached.  This  period  lasts 
several  days ;  sometimes  two  or  three  weeks  even  elapse  before  all 
the  crusts  separate.  In  the  meantime  the  patient  gradually  re- 
covers his  health  and  former  strength.  After  the  fall  of  the  crust, 
the  cicatrix  underneath  presents  a  reddish  appearance.  This  color 
gradually  fades,  and  there  remains  an  irregular  depression,  or  pit, 
of  a  lighter  color  than  the  surrounding  surface;  and  if  there  has 
been  a  full  development  of  the  eruption,  disfiguring  the  patient  for 
life. 

Such  is  the  clinical  history  of  variola,  when  it  is  favorable,  and 
its  course  is  regular.  The  disease  is  sometimes  irregular.  In  rare 
instances  the  eruption  occurs  almost  at  the  commencement  of  the 
disease.  The  form  is  then  very  apt  to  be  confluent.  There  are 
irregularities,  also,  in  consequence  of  diarrhcea,  hemorrhages,  or 
other  complications.  I  have  known  the  eruption  appear  first  on 
the  limbs,  and  last  on  the  trunk  and  face,  and  the  appearance  of 
the  eruption  is  not  always  the  same.  In  the  ancemic  and  feeble 
child  it  often  presents  a  pale  color,  with  some  induration  at  its 
base,  but  without  the  red  areola  around  it,  or  with  this  quite  in- 
distinct. In  rare  instances  the  vesicles  have  a  reddish  color,  their 
contents  beins;  tinned  with  blood.  This  form  of  variola  is  desip-- 
nated  hemorrhagic.  It  indicates  a  profoundly  altered  state  of  the 
blood.  The  eruption  in  this  form  is  of  small  size,  and  if  the  jjock 
is  broken,  blood  oozes  from  it. 

Varioloid. — The  course  of  varioloid  is  similar  to  that  of  variola, 
but  it  is  somewhat  shorter.  It  commences  with  rigors,  followed 
by  fever,  headache,  pain  in  the  back,  vomiting,  drowsiness,  and 
sometimes  delirium,  or  even  convulsions.  The  symptoms  in  the 
stage  of  invasion  are,  indeed,  the  same  in  character,  and  often 
nearly  as  severe  as  in  variola.  With  the  initial  symptoms,  there 
is  also  sometimes  a  scarlatiniform  eruption,  so  that  the  disease 
may  at  first  be  mistaken  for  scarlatina.  On  the  third  or  fourth 
day  the  variolous  eruption  commences.  The  number  of  pocks  is 
commonly  few,  often  not  more  than  twelve  to  twenty.  In  the 
mildest  form  of  varioloid,  if  the  physician  is  not  summoned  in  the 


206  VARIOLOID. 

stage  of  invasion,  lie  is  not  apt  to  be  called  at  all,  so  that  the  pa- 
tient may  pass  through  the  disease  in  ignorance  of  its  nature.  I 
have  known  this  occur,  the  true  character  of  the  affection  not  being 
ascertained  till  others  were  affected,  either  with  variola  or  vario- 
loid. 

The  eruption  pursues  a  more  rapid  course  in  varioloid  than  in 
the  unmodified  disease.  By  the  fifth  or  sixth  day  the  pustules  are 
fully  developed,  though  often  smaller  and  less  likely  to  be  ruptured 
than  in  variola.  Often,  in  varioloid,  the  eruption  aborts.  It  re- 
mains papular  two  or  three  days,  and  then  declines,  or  it  may  reach 
the  vesicular  stage,  and  decline  without  pustulation. 

The  constitutional  symptoms  in  varioloid  decline  with  the  com- 
mencement of  the  eruptive  stage.  The  secondary  fever  is  slight  or 
absent. 

Such  is  the  usual  mild  course  of  varioloid,  but  not  always.  If 
several  years  have  elapsed  since  the  vaccination,  its  j^i'otective 
power  is  greatly  impaired,  and  varioloid  may  then  exhibit  as  severe 
a  form  as  ordinary  smallpox.     In  some  instances  it  is  fatal. 

The  term  varioloid  is,  as  has  been  stated,  applied  to  cases  of 
variolous  disease  where  there  has  been  previous  vaccination.  It 
is  also  applied  by  writers  to  second  attacks,  whether  the  first 
occurred  from  infection  or  from  variolous  inoculation,  but  such 
cases  are  rare. 

Mode  of  Death. — Death  in  smallpox  occurs  in  several  different 
ways.  The  most  fatal  period  is  the  pustular  stage.  Feeble  chil- 
dren not  unfrequently  die  from  exhaustion  at  or  about  the  time 
that  the  pustules  attain  their  greatest  size.  The  eruption  appears 
and  becomes  developed  as  usual,  but  there  are  evidences  of  weak- 
ness in  the  patient,  and  suddenly  the  progress  of  the  vesicle  or  pus- 
tule ceases.  It  begins  to  subside,  and  its  walls  shrivel.  There  is 
evidently  absorption,  in  part,  of  the  liquid  contents.  These  pheno- 
mena are  of  the  gravest  character.  Death  is  the  common  result, 
and  within  twenty-four  hours.  In  other  cases  death  occurs  from 
apnoea.  The  pock  increasing  in  size  in  the  larynx  and  trachea, 
obstructs  inspiration,  or  there  may  be  the  formation  of  a  pseudo- 
membrane,  as  in  true  croup.  This  is  not  an  unusual  mode  of  death 
in  young  children,  in  whom  the  calibre  of  the  larynx  and  trachea 
is  small.  Sometimes  convulsions  iind  coma  occur  in  the  last  hours 
of  life.  In  other  cases  the  stage  of  desquamation  is  reached,  but 
convalescence  does  not  occur.  The  patient  each  day  becomes  more 
anpemic  and  feeble,  and  finally  death  results  from  failure  of  the 
vital  powers.     Again,  after  smallpox  has  run  its  course,  purpura 


ANATOMICAL    CHARACTERS.  207 

hfemorrliagica  may  be  developed.  Hemorrhages  occur  from  the 
gums,  throat,  nostrils.  Elood  is  vomited,  and  evacuated  in  the 
stools.  I  have  known  death  to  occur  in  all  these  ways,  but  that 
from  purpura  is  least  frequent.  Sometimes,  as  in  scai'let  fever, 
death  occurs  suddenly  and  unexpectedly  in  confluent,  and  even  in 
discrete  variola,  when  the  previous  s3miptoms  had  apparently  been 
favorable.  The  patient  is  overpowered  by  the  intensity  of  the  virus. 

Anatomical  Characters. — In  those  who  have  died  of  variola, 
without  inflammatory  or  other  complication,  the  heart-clots  have 
been  found  small,  dark,  and  soft.  The  blood  is  dark  and  thin. 
The  vessels  of  the  brain  and  its  membranes  are  injected,  so  that 
numerous  red  points  appear  on  the  cut  surface  of  this  organ.  The 
vessels  of  the  lungs  and  the  abdominal  organs  are  congested,  while 
the  muscles  present  a  deep  red  color.  The  variolous  eruption  pene- 
trates more  deeply  than  that  of  any  other  exanthematic  fever.  It 
has  been  stated  elsewhere  that  it  occurs  not  only  on  the  skin,  but 
often  on  the  surface  of  the  mouth,  fauces,  and  air-passages.  The 
mucous  membrane  in  these  situations  is  frequently  also  the  seat  of 
erythematic  inflammation,  being  thickened  and  softened,  and  in 
some  parts,  as  the  larynx,  a  pseudo-membrane  is  occasionally  pro- 
duced, as  in  croup.  This  inflammation,  erythematic  or  pseudo- 
membranous, may  occur  without  as  well  as  with  the  presence  of 
the  specific  eruption. 

The  eruption  very  seldom,  perhaps  never,  appears  upon  the  gastro- 
intestinal surface,  but  the  solitary  follicles  and  patches  of  Peyer 
are  often  enlarged,  as  in  some  other  zymotic  aftections.  The  liver, 
spleen,  and  kidneys  are  commonly  congested  in  those  who  have  died 
of  variola.  The  spleen,  especially,  is  increased  in  volume  and  soft- 
ened ;  the  kidneys  are  enlarged,  as  if  from  commencing  nephritis, 
and  sometimes  softened. 

The  minute  structure  of  the  pock  is  described  by  Rilliet  and 
Barthez,  and  others.  The  vesicle  is  multilocular,  consisting  of 
at  least  five  or  six  compartments,  with  distinct  partitions.  Its 
centre  is  united  by  fibrous  bands  to  the  derm  beneath,  which  union 
gives  rise  to  the  umbilicated  appearance.  The  giving  way  of  these 
minute  bands  in  the  pustular  stage  occurs  when  the  form  changes 
from  the  umbilicated  to  the  convex.  In  the  pustular  stage  also, 
according  to  some,  a  fibrinous  formation  occurs  within  the  pustule  ; 
according  to  others,  this  substance  is  of  the  nature  of  the  epidermis, 
presenting  the  appearance  of  the  cuticle  when  macerated.  Mixed 
with  this  epidermic  or  fibrinous  formation  are  pus  cells. 


208  VARIOLOID. 

Complications. — There  are  several  different  complications  of  va- 
riola. One  is  salivation.  This  is  common  in  the  adult,  but  rare 
in  the  child.  When  it  occurs  in  the  child,  it  is  slight,  commencing 
with  or  about  the  time  of  the  eruption,  and  disappearing  in  from 
one  to  four  or  five  days.  Ophthalmia  is  another  complication.  Sim- 
ple conjunctivitis,  often  quite  intense,  may  occur  in  consequence 
of  pustules  developed  under  the  lids.  This  inflammation  subsides 
without  injury  to  the  eye,  as  the  primary  disease  abates.  A  more 
serious  inflammation  occurs  at  an  advanced  stage  of  the  disease, 
commencing  in  or  near  the  desquamative  period.  This  produces 
more  or  less  chemosis,  and  sometimes  opacity  or  ulceration  of  the 
cornea.  A  similar  inflammation  may  occur  in  the  ear,  giving  rise 
to  otorrhcea,  and  even  in  some  patients  to  rupture  of  the  drum  of 
the  ear.  Abscesses  in  the  subcutaneous  cellular  tissue  have  been 
occasionally  observed,  especially  in  the  confluent  form.  Subcutane- 
ous infiltration  and  feebleness  of  constitution  favor  their  occurrence. 
Suppuration  within  the  joints  is  a  somewhat  rare  complication  or 
sequel,  rendering  convalescence  protracted,  if,  indeed,  the  case  is 
not  fatal. 

M.  Beraud  has  published  a  memoir  to  show  that  orchitis  com- 
plicates variola  in  the  male,  and  ovaritis  in  the  female.  These 
inflammations  are  believed  to  be  accompanied  by  a  small  and  im- 
perfect variolous  eruption  upon  the  tunica  vaginalis  and  the  peri- 
toneal covering  of  the  ovary.  Trousseau  states  that  he  has  often 
met  this  complication  in  the  male,  since  his  attention  was  called  to 
it.  It  is  mild,  and  subsides  with  the  disappearance  of  the  eruption. 
Laryngitis,  simple  or  diphtheritic,  bronchitis,  pneumonia,  pharyn- 
gitis, purpuric  hemorrhages,  gangrene  of  the  mouth  or  other  parts, 
oedema  pulmonum,  and  oedema  glottidis  are  occasional  complica- 
tions, some  of  which  are  frequent,  others  rare. 

Prognosis. — This  depends  on  the  age,  vigor  of  system,  form  of 
the  disease,  and  the  presence  or  absence  of  complications.  The 
younger  the  child,  the  greater  the  danger.  Trousseau  says :  "  Con- 
fluent variola,  and  even  discrete  variola,  are  almost  always  fatal  in 
individuals  less  than  two  years  old."  Above  the  age  of  three  or 
four  years  discrete  variola  usually  ends  favorably,  but  the  confluent 
form  is  still,  as  a  rule,  fatal.  Varioloid  in  the  child  is  a  mild 
disease,  terminating  favorably  in  a  large  proportion  of  cases.  It  is 
milder  at  this  age  than  in  the  adult,  on  account  of  the  more  recent 
period  of  vaccination,  and  if  a  case  of  supposed  varioloid  is  severe, 
and  the  eruption  abundant,  it  is  probable  that  the  vaccination  was 
spurious. 


TREATMEXT,  209 

It  is  not  necessary,  from  wliat  lias  been  said,  to  specify  tlie 
favorable  prognostic  signs.  The  unfavorable  prognostics  are,  great 
violence  of  the  initial  symptoms ;  early  appearance  of  the  eruption  ; 
an  abundant  eruption,  especially  if  pale,  and  without  swelling  of 
the  surface ;  rapid  decline  of  the  eruption  in  the  vesicular  or  pus- 
tular stage ;  hemorrhagic  eruption,  or  hemorrhages  from  the  sur- 
faces ;  fever  continuing  after  the  appearance  of  the  eruption ; 
diarrhoea  persisting  beyond  the  third  or  fourth  day ;  delirium  or 
great  drowsiness ;  a  frequent  and  feeble  pulse ;  and,  finally,  ob- 
structed respiration — if  slow,  indicating  a  pseudo-membrane  or 
variolous  eruption  in  the  larynx  or  trachea — if  rapid,  indicating 
bronchitis  or  pneumonia. 

Diagnosis. — The  diagnosis  cannot  be  made  with  certainty  prior 
to  the  eruptive  stage.  If,  however,  smallpox  is  prevalent,  if  the 
patient  has  not  been  vaccinated,  and  the  symptoms  which  pertain 
to  the  period  of  invasion  are  present,  as  headache,  pain  in  small  of 
back,  repeated  vomiting,  drowsiness,  and  perhaps  convulsions,  there 
is  ground  for  the  gravest  suspicion.  If,  in  addition  to  these  symp- 
toms, reddish  points  begin  to  appear  on  the  second  or  third  day, 
the  diagnosis  may  be  made  with  confidence.  At  this  early  period, 
even  before  there  is  any  distinct  cutaneous  eruption,  ash-colored 
spots  may  sometimes  be  observed  on  the  buccal  or  faucial  surface, 
the  commencement  of  the  variolous  eruption ;  these  possess  con- 
siderable diagnostic  value. 

The  scarlatiniform  efflorescence,  in  the  first  stage  of  variola, 
sometimes  leads  to  the  belief  that  the  disease  is  scarlet  fever.  The 
absence  of  the  pharyngitis,  and  the  appearance  of  the  variolous 
eruption  soon  after  the  efflorescence,  correct  the  diagnosis.  Small- 
pox has,  in  the  beginning  of  the  eruptive  period,  sometimes  been 
mistaken  for  measles.  The  points  involved  in  the  differential 
diagnosis  have  been  presented  in  treating  of  that  disease.  After 
the  development  of  the  eruption  it  may  be  mistaken  for  varicella. 
The  eruption  of  varicella  is,  however,  preceded  by  symptoms  which 
are  milder  and  of  shorter  duration,  and  its  appearance  is  different. 
It  is  irregular,  instead  of  round;  is  not  umbilicated,  and  it  does  not 
have  the  round,  inflamed,  and  indurated  base,  which  characterizes 
the  variolous  eruption.  The  eruption  of  ecthyma  is  sometimes 
umbilicated,  but  the  symjDtoms  of  ecthyma  and  variola,  and  the 
progress  of  the  eruptions  in  the  two  diseases,  are  ver}^  different. 

Treatment. — Smallpox,  like  the  other  essential  fevers,  is  self- 
limited,   and   therefore   the   constitutional   treatment   should   be 
sustaining  and  palliative."    In  the  first  stages  of  the  disease,  the 
14 


210  VAEIOLOID. 

diet  should  be  simple ;  gentle  laxatives  and  refrigerant  drinks  are 
required  if  there  is  much  febrile  excitement.  Lemonade  is  a 
grateful  drink,  and  may  be  given  in  moderate  quantity.  Spiritus 
Mindereri  or  carbonic  acid  water  may  be  allowed.  As  the  disease 
advances,  more  nutritious  food  should  be  recommended;  and  in 
severe  cases  carbonate  of  ammonia,  and  even  alcoholic  stimulants, 
are  required. 

As  confluent  smallpox  is  nearly  always,  and  the  discrete  form 
often,  fatal  in  infancy,  the  physician  should  carefully  watch  the 
progress  of  the  case  in  the  infant.  By  judicious  treatment,  some, 
in  this  period  of  life,  may  be  saved,  who  otherwise  would  perish. 
In  the  infant,  depressing  measures  should  be  avoided.  A  laxative 
may  be  given,  at  first,  if  there  is  much  fever,  and  the  bowels  are 
constipated;  but  the  diet  should  be  nutritious,  and  many  soon  re- 
quire tonics  and  stimulants.  If  the  pulse  become  more  frequent  and 
feeble,  or  if,  with  frequency  of  the  pulse,  the  face  and  extremities 
become  cool,  or  if,  in  the  vesicular  or  pustular  stage,  the  eruption 
suddenly  subsides,  alcoholic  stimulants  must  be  immediately  em- 
ployed, or  the  patient  dies. 

Such  is  an  outline  of  the  constitutional  treatment  required  in 
smallpox.  Sydenham  inculcated  a  mode  of  treatment  which 
experience  has  shown  to  be  injurious  in  infancy  and  childhood. 
He  had  observed  that  the  severity  of  the  disease  was  ordinarily 
proportionate  to  the  amount  of  eruption,  and  concluded  from  this 
fact  that  measures  which  retarded  the  development  of  the  eruption 
were  salutary ;  cold  drinks,  a  cold  apartment,  scanty  covering  of 
the  body,  cathartics  that  caused  derivation  of  blood  from  the  sur- 
face, even  sometimes  the  abstraction  of  blood,  were  considered, 
according  to  Sydenham's  theory,  to  be  useful  as  means  of  preventing 
full  development  of  the  eruption. 

Sydenham's  treatment,  however  appropriate  it  might  sometimes 
be  in  case  of  robust  adults,  is  unsuitable  for  children,  because  they 
do  not,  as  a  rule,  tolerate,  in  this  disease,  measures  which  reduce 
the  strength.  Moreover,  smallpox  is  rendered  more  dangerous 
by  what  Rilliet  and  Barthez  designate  perturbating  treatment — 
treatment  which  renders  it  abnormal.  The  regular  appearance 
and  development  of  the  eruption  are  requisite  in  order  that  the 
case  may  progress  favorably.  On  the  other  hand,  the  opposite 
plan  of  treatment,  which  families,  if  left  to  themselves,  are  apt  to 
adopt — namely,  the  employment  of  measures  to  promote  perspira- 
tion, as  hot  drinks,  and  confinement  in  a  heated  room — is  also 
injurious. 


TREATMENT.  211 

The  patient  should  be  kept  in  a  temperature  such  as  lie  lias  been 
accustomed  to,  and  such  as  is  agreeable  to  him;  his  diet  sliould  be 
simple  and  nutritious ;  laxative  medicine  should  only  be  given  to 
procure  the  natural  evacuations.  In  smallpox,  as  in  all  infectious 
diseases,  free  ventilation  of  the  apartment  is  required. 

While  the  general  eruption  in  smallpox  should  not  Ije  interfered 
with,  it  is  proper  to  endeavor  to  diminish,  so  far  as  possible,  the 
size  of  the  pocks,  on  parts  exposed  to  view,  so  as  to  prevent  dis- 
figurement. Prof.  Flint,  in  his  Treatise  on  the  Practice  of  3Iedicine^ 
has  published  an  excellent  summary  of  the  various  measures  which 
have  been  recommended  for  accomplishing  this  end.  First:  The 
opening  and  breaking  up  of  the  vesicle  by  means  of  a  fine  needle. 
This  is  tedious  practice  in  confluent  variola,  but  it  can  readily  be 
performed  in  the  discrete  form — at  least  as  regards  the  vesicles 
upon  the  face.  This  treatment  Avas  proposed  by  Rayer,  and  it  is 
recommended  by  many  who  have  tried  it.  Secondly :  After  the  evac- 
uation of  the  liquid,  the  cauterization  of  the  vesicle  by  a  pointed 
stick  of  nitrate  of  silver.  Rilliet  and  Barthez  say,  in  reference  to 
this  mode  of  treatment,  "  Individual  cauterization  of  the  pustules 
is,  on  the  other  hand,  an  almost  infallible  means  of  causing  them 
to  abort.  To  be  successful,  it  is  necessary  to  penetrate  into  the 
interior  of  the  pustule  with  a  pointed  craj^on  of  nitrate  of  silver, 
in  order  to  cauterize  the  derm.  ...  It  is  only  the  first  or  second 
day  of  the  eruption  that  it  (cauterization)  has  certain  success; 
nevertheless,  we  have  often  seen  it  succeed  the  third  or  the  fourth 
day,  or  even  the  fifth." 

Thirdly:  The  application  of  tincture  of  iodine  once  or  twice 
daily  over  the  eruption  when  in  the  papular  stage.  Some  writers, 
who  have  employed  iodine,  state  that  it  does  not  prevent  pitting, 
but  diminishes  it.  Fourthly:  The  exclusion  of  light  and  air  by 
means  of  a  plaster.  A  mixture  containing  tannate  of  iron  has; 
been  employed  for  this  purpose  in  one  of  our  hospitals.  This  pro- 
duces a  black  mask.  Light  and  air  may  also  be  excluded  by- 
smearing  the  face  with  sweet  oil,  and  dusting  twice  daily  upon  the 
oiled  surface  a  powder  containing  equal  parts  of  subnitrate  of'  bis- 
muth and  prepared  chalk.  Fifthly:  The  application  of  mild  mer- 
curial ointment  upon  the  face  or  other  parts  of  the  surface,  where 
it  is  desirable  to  render  the  eruption  abortive.  This  mode  of  treat- 
ment does  diminish  the  size  of  the  vesicles  and  the  pitting,,  but  I 
should  not  recommend  it  for  children.  I  have  known  in  the  adult 
severe  mercurialization  from  its  employment  for  four  or  five  days, 
and,  though  young  children  do  not  exhibit  so  readily  the  effects  of 


212  VACCINIA. 

mercury,  the  use  of  the  ointment,  unless  for  a  very  limited  period, 
increases,  in  my  opinion,  their  feebleness,  and  diminishes  the 
chance  of  their  recovery.  Calamine  made  into  a  paste  with  sweet 
oil  is  said  to  be  equally  effectual  with  mercurial  ointment,  and  it 
jiroduces  no  constitutional  effect.  Its,  effect  is  obviously  similar  to 
that  of  the  bismuth  and  chalk  employed  with  sweet  oil  as  stated 
above.  Of  late,  I  have  employed  pulverized  charcoal  made  into  a 
thin  paste  with  sweet  oil  or  glycerine,  and  applied  daily  or  twice 
daily  to  the  face.  It  effectually  excludes  the  light,  and  the  result 
has  been  so  good  as  regards  pitting,  that  I  shall  continue  to  use  it. 
Poultices,  collodion,  a  solution  of  gutta  percha  in  chloroform,  have 
been  recommended,  among  other  substances,  by  good  observers. 
If  fissures  or  excoriations  occur,  an  application  may  be  made  of 
oxide  or  carbonate  "of  zinc  in  glycerine,  one  drachm  to  the  ounce. 
The  prevention  of  smallpox,  so  far  as  practicable,  is  one  of  the 
important  incidental  duties  of  the  physician.  Isolation  of  the 
patient,  and  precautions  in  reference  to  his  clothes  and  bedding, 
are  imperatively  required,  so  great  is  the  infectiousness  of  this  dis- 
ease. The  only  certain  means  of  prevention  is  confessedly  vacci- 
nation, and  providentially  the  incubative  period  of  the  vaccine 
disease  is  much  less  than  that  of  variola.  Therefore,  smallpox 
may  be  prevented  after  the  virus  is  received  in  the  system,  by 
timely  and  successful  vaccination.  Vaccination,  at  any  period 
between  the  time  of  exposure  and  the  commencement  of  the  symp- 
toms of  invasion,  will  either  prevent  the  occurrence  of  smallpox  or 
modify  it.  If  the  symptoms  of  invasion  have  already  commenced, 
it  is  uncertain  whether  it  produces  any  modifying  effect. 


CHAPTER   IV. 

VACCINIA. 


Vaccixia  is  a  mild  eruptive  disease,  which  occasionally  occurs 
among  cattle,  and  has  been  propagated  from  them  to  man.  It  is 
characterized  by  the  appearance  upon  the  surface  of  one  or  more 
papules,  which  soon  become  vesicular,  and  then  pustular.  It  is 
communicable  by  contact,  but,  unlike  the  other  eruptive  fevers,  it 
is  not  infectious  in  man.     It  is  inoculable,  both  by  tbe  liquid  con- 


VACCINIA.  213 

tained  in  the  vesicle,  wliich  is  designated  vaccine  lymph,  and  l»y 
the  scab  which  results  from  the  desiccation  of  the  pustule. 

To  Gloucestershire,  England,  the  honor  belongs  of  discovering 
and  popularizing  the  fact  that  vaccinia,  a  mild  and  comparatively 
harmless  disease,  is  transmissible  from  the  cow  to  man,  and  that  it 
affords  protection  from  smallpox.  It  appears  that  a  vague  opinion 
prevailed  among  the  farmers  of  this  dairying  section,  that  a  dis- 
ease, which  has  since  been  designated  vaccinia,  was  occasionally 
received  from  the  cow  in  milking,  the  virus  passing  from  a  pustule 
on  the  teat  to  a  sore  or  chap  on  the  hand  of  the  milker,  and  that 
those  who  thus  contract  the  disease  receive  immunity  from  small- 
pox. As  usually  happens  with  important  discoveries,  so  dull  of 
apprehension  is  human  intellect,  these  people,  to  whom  Providence 
had  revealed  so  important  a  fact,  were  blind  to  its  real  value. 
Finally,  in  the  year  1774,  Benjamin  Jesty,  whom  the  world  has 
not  sufficiently  honored,  "  an  honest  and  upright  man,"  according 
to  his  epitaph,  a  farmer  of  Gloucestershire,  had  the  courage  to 
vaccinate  his  wife  and  two  children.  His  excellent  moral  character 
did  not  shield  him.  He  was  regarded  by  his  neighbors  as  an  inhu- 
man brute,  who  had  performed  an  experiment  on  his  own  family, 
the  tendency  of  which  might  be  to  transform  them  into  beasts 
with  horns. 

The  first  essay  in  vaccination  appears  to  have  been  entirely  suc- 
cessful, but  the  prejudice  against  the  operation  continued.  A 
fifth  of  a  century  passed,  during  which  there  was  no  extension  of 
the  benefits  of  this  great  discovery.  At  last,  towards  the  close  of 
the  last  century.  Dr.  Edward  Jenner,  a  physician  of  Gloucester- 
shire, and  inoculator  of  his  district,  began  to  investigate  this 
disease  of  the  cow,  about  which  little  was  known,  and  the  grounds 
for  the  belief  that  it  aftbrded  protection  from  smallpox.  Fortu- 
nately for  the  world,  Jenner  had  been  educated  under  John 
Hunter,  and  had  learned  from  his  great  master  to  study  nature 
rather  than  books,  to  be  guided  by  experience  and  observations 
rather  than  by  the  dogmas  of  his  predecessors  or  of  the  schools. 

Jenner  performed  his  first  vaccination  on  the  14th  of  May,  1796, 
twenty-two  3^ears  after  Benjamin  Jesty  had  lost  his  good  name 
among  his  neighbors  for  vaccinating  his  own  family.  The  popu- 
larizing of  vaccination,  mainly  through  Jenner's  perseverance, 
aftbrds  one  of  the  most  interesting  and  instructive  chapters  in 
the  history  of  medical  science.  How  he  went  up  to  London, 
full  of  the  importance  of  the  discovery,  and  was  there  advised  by 
his  medical  friends  to  desist  from  his  wild  schemes,  lest  he  should 


214  VACCINIA. 

injure  the  reputation  which  he  had  gained  by  publishing  a  credit- 
able paper  on  the  cuckoo ;  how  he  was  allowed  to  vaccinate  in  the 
hospital  wards,  and  gained  some  adherents  to  the  new  faith  among 
the  leading  physicians  of  the  metropolis;  and  finally,  how,  as  the 
claims  of  vaccination  began  to  be  recognized,  at  the  close  of  the 
last  century  and  commencement  of  the  present,  a  most  acrimo- 
nious discussion  arose,  which  filled  all  the  medical  journals  of  that 
period.  The  opponents  of  vaccination  resorted  to  every  device  to 
prevent  the  acceptance  of  Jenner's  views.  They  attempted  to  pre- 
judice the  people  against  them  by  specious  arguments,  by  ridicule, 
and  even  by  pictures.  One  of  the  leading  journals  contained  the 
caricature  of  a  cow  covered  with  sores,  and  devouring  children, 
and  it  was  urged  that  vaccination  was  a  bestial  operation,  de- 
grading man  to  the  level  of  the  brute.  But  the  truth  had  gained 
a  firm  hold,  and  the  practice  of  vaccination  extended. 

The  discovery  of  vaccinia,  and  of  its  protective  power,  cannot 
be  too  highly  appreciated.  It  has,  probably,  done  more  to  relieve 
human  suffering  than  any  other  discovery  of  the  last  one  hundred 
years,  unless  we  except  that  of  anaesthetics,  and  more  to  save  human 
life  than  any  other  instrumentality  of  a  purely  ph^'sical  kind. 

The  fact  was  established  in  the  time  of  Jenner  that  the  virus  of 
smallpox  inoculated  in  the  cow  produced  vaccinia,  which  in  its 
propagation  back  to  man  never  returned  to  its  original  form,  but 
always  remained  vaccinia.  Moreover,  Jenner  believed  that  the 
disease  known  in  the  horse  as  the  grease  was  identical  in  nature 
with  vaccinia  in  the  cow.  He  failed,  however,  in  his  experiments 
to  communicate  vaccinia  from  the  horse,  but  other  experimenters 
have  been  more  successful.  In  1801,  a  Dr.  Loy,  of  the  county  of 
York,  England,  met  two  cases  of  vaccinia  in  persons  who  had  taken 
care  of  a  horse  afi:ected  with  the  grease,  and,  from  the  lymph  which 
he  obtained,  was  able  to  produce  vaccinia  in  the  cow.  In  1805, 
Viborg,  a  Danish  veterinary  surgeon,  after  many  failures,  succeeded 
also  in  communicating  vaccinia  to  the  cow  by  means  of  the  virus 
taken  from  a  horse. 

From  this  time  little  light  was  thrown  on  this  subject  till  within 
the  last  twelve  years.  Although  Loy  and  Viborg,  and  perhaps  a 
few 'others,  had  recorded  their  success,  other  experimenters  had 
failed  to  communicate  vaccinia  from  the  horse.  In  the  absence  of 
additional  cases,  the  profession  began  to  question  whether  there 
might  not  have  been  some  error  in  the  observations  of  the  gentle- 
men whose  names  I  have  mentioned,  and  the  problem  was  still 


VACCINIA.  215 

regarded  as  undetermined,  whether  a  disease  identical  wilh  vac- 
cinia occurred  in  the  horse,  or  a  disease  which  might  communicate 
vaccinia  to  the  cow  or  to  man. 

Observations  confirmatory  of  those  of  Loy  and  Viborg  were  at 
length,  however,  made,  which  must  be  regarded  as  conclusive.  In 
1856,  in  the  department  d'Eure-et-Loir,  France,  M.  Pichot  was 
consulted  by  a  boy  who  had  on  the  back  of  his  hands  vaccine  pus- 
tules, which  had  apparently  reached  the  eiglith  or  ninth  day.  He 
had  not  taken  care  of  nor  been  in  contact  with  a  cow,  but  had  a 
few  days  before  taken  care  of  a  horse  affected  with  the  grease. 
Vaccination  was  performed  by  means  of  tlie  lymph  taken  from 
these  pustules,  and  genuine  vaccinia  was  produced. 

Again,  in  1860,  an  epidemic  prevailed  among  the  horses  in 
Rieumes  and  Toulouse,  France.  A  mare  sickened  with  the  dis- 
ease, and  there  was  swelling  of  the  hough,  with  discharge  of  sa- 
nious  matter.  M.  Delafosse  vaccinated  two  cows  with  this  matter, 
and  communicated  genuine  vaccinia.  This  epidemic  was  believed 
by  the  veterinary  surgeons  to  be  an  eruptive  fever,  differing  in  its 
nature  somewhat  from  the  disease  or  diseases  which  have  ordina- 
rily been  designated  the  grease.  It  has  been  conjectured  that  two 
or  more  distinct  affections  of  the  horse  have  the  same  appellation, 
one  of  which,  it  is  now  admitted,  is  identical  with  vaccinia  of  the 
cow,  and  may  communicate  it.  And  the  reason  why  so  many  ex- 
perimenters have  failed  to  vaccinate  the  cow  from  the  horse  is  that 
they  have  used  the  virus  of  the  wrong  disease,  or  have  taken  mat- 
ter from  horses  which  had  been  affected  with  the  true  disease,  but 
from  ulcers  which  had  lost  their  specific  character. 

Prior  to  the  time  of  Jenner  variolous  inoculation  was  practised 
in  most  civilized  countries,  as  variola  produced  in  this  way  was 
found  to  be  milder  than  when  arising  from  infection.  This  prac- 
tice is  now  obsolete ;  forbidden  in  some  places  by  legislative  enact- 
ments. It  is  superseded  by  vaccination.  Vaccination,  or  the  in- 
troduction of  vaccine  lymph  into  the  system,  is  quickly  and  con- 
venientl}^  performed  by  scarifying  with  a  lancet,  and  pressing  into 
the  incisions  the  lymph,  or  a  little  of  the  scab  pulverized,  and  dis- 
solved in  a  drop  of  cold  water.  It  may  also  be  performed  by 
scraping  off  the  epidermis  with  the  edge  of  the  instrument  till  the 
blood  begins  to  ooze ;  and  also,  though  with  less  certainty  of  suc- 
cess, by  puncturing  the  skin  with  the  point  of  the  lancet,  or  by  an 
instrument  called  the  vaccinator. 

If  the  child  has  a  vascular  npevus,  this  may  be  selected  as  the 
point  of  vaccination.     Unless  of  large  size,  it  can  usually  be  cured 


216  VACCINIA. 

by  the  inflammation  whicli  vaccinia  produces.  Statistics  collected 
by  Simon,  as  well  as  Marson,  show  that  of  those  who  contract 
varioloid,  the  larger  the  number  of  vaccine  cicatrices  the  milder 
the  disease,  and  the  less  the  proportionate  number  of  deaths.  In 
Simon's  statistics  of  those  who  stated  that  they  had  been  vacci- 
nated, but  who  presented  no  cicatrix,  21f  per  cent,  died;  of  those 
who  had  one  cicatrix,  7|  per  cent,  died ;  of  those  who  had  two,  4|- 
per  cent,  died;  of  those  who  had  three,  If  per  cent,  died;  while 
of  those  who  had  four  or  more  cicatrices,  only  |  per  cent.  died. 
These  statistics  would  seem  to  indicate  the  propriety  of  vaccinating 
in  several  places.  But,  so  far  as  appears,  when  two  or  more  cica- 
trices were  observed,  the  patients  may  have  been  vaccinated  at 
different  times,  at  intervals,  perhaps,  of  several  years,  and  if  so, 
the  inference  would  not  follow  that  more  complete  protection  is 
produced  by  vaccinating  in  several  places,  than  in  one.  Moreover, 
if  vaccination  is  performed  in  the  usual  manner  by  several  inci- 
sions on  the  arm,  and  the  virus  is  fresh  and  active,  usually  two  or 
more  distinct  vesicles  arise,  which  miite  in  their  development,  and 
probably  protect  the  system  as  much  as  if  they  were  separated  by 
a  wider  space. 

Appearances,  Symptoms. — In  genuine  vaccination  no  effect  is 
observed,  except  the  slight  inflammation  due  to  the  operation,  till 
the  close  of  the  third  day.  Then  the  specific  inflammation  com- 
mences. This  is  indicated  by  a  small  red  point,  at  first  scarcely 
visible,  indurated  and  slightly  elevated,  as  determined  by  the 
touch,  rather  than  by  the  eye.  This  increases,  and  on  the  fifth 
day  the  cuticle  over  the  inflamed  part  begins  to  be  raised  by  a 
transparent  and  thin  liquid.  The  vesicle  increases  in  diameter, 
and  by  the  sixth  day  presents  an  umbilicated  appearance,  and  is 
surrounded  by  a  faint  and  narrow  red  zone.  At  the  close  of  the 
eighth  day  the  vesicle  is  fully  developed.  Its  size  varies  consider- 
ably. It  is  usually  from  a  sixth  to  a  third  of  an  inch  in  diameter, 
and  oval  or  circular.  If  the  vaccination  has  been  performed  by 
incisions,  the  size  of  the  matured  vesicle  may  be  considerably 
larger,  and  its  shape  irregular,  in  consequence  of  the  union  of  two 
or  more  vesicles.  Tlie  eruption  now  presents  a  whitish  or  pearl- 
colored  appearance,  due  to  the  whiteness  of  the  cuticle,  and  the 
transparence  of  the  liquid  underneath.  If  the  vaccination  was 
performed  by  incisions,  it  is  not  unusual  to  observe  over  the  centre 
of  the  vesicle,  and  adhering  to  it,  a  small  yellowish  scab,  which 
has  resulted  from  the  scarification,  and  which  contains  none  of  the 
virus. 


ANOMALIES,    COMPLICATION'S,    AND    SEQUELS.  217 

The  vaccine  vesicle,  like  that  of  variola,  consists  of  compartments, 
commonly  eight  or  ten,  with  complete  partitions,  so  that  there  is  no 
intercommunication.  On  the  ninth  day  the  inflamed  areola  l)e- 
comcs  more  distinct,  and  its  diameter  rapidly  increases.  Its  color 
is  deep  red,  its  temperature  is  considerably  elevated,  and  it  is  ac- 
companied by  more  or  less  induration  of  the  subcutaneous  tissue, 
and  it  is  tender  to  the  touch.  On  the  tenth  da}^  the  pock  has 
reached  its  full  development.  The  areola  then  extends  from  one 
to  two  inches  away  from  the  vesicle,  becoming  fainter  at  its  outer 
circumference,  and  gradually  disappearing  in  the  healthy  skin. 
The  shape  of  the  outer  circumference  of  the  areola  is  irregular, 
projecting  further  at  one  point  than  another,  though  its  general 
form  is  circular. 

On  the  tenth  day,  when  the  inflammation  has  reached  its  maxi- 
mum, the  heat,  itching,  and  tenderness  in  and  around  the  pock 
are  such  that  the  child  is  often  feverish  and  restless.  Occasion- 
ally the  glands  of  the  axilla  become  swollen  and  tender.  In  other 
cases,  in  which  there  is  but  a  moderate  amount  of  inflammation, 
the  constitutional  disturbance  is  slight. 

At  the  close  of  the  tenth  day,  or  on  the  eleventh,  the  inflamma- 
tion begins  to  decline ;  the  areola  becomes  narrower  and  then  dis- 
appears ;  the  induration  and  tenderness  abate;  and  with  this  change 
the  jDUstule  desiccates,  its  liquid  is  absorbed,  and  there  results  a 
brownish  or  a  dark  mahogany-colored  scab,  which  is  detached, 
ordinarily,  between  the  fourteenth  and  twenty-first  days.  The 
cicatrix,  at  first  reddish,  like  all  recent  cicatrices,  gradually  be- 
comes paler,  and  remains  whiter  than  the  surrounding  integument. 
It  presents  several  minute  depressions  or  pits,  which  indicate  the 
genuineness  of  the  vaccination. 

Anomalies,  Complications,  and  Sequels. — The  vesicle  is  often 
broken,  accidentally,  or  by  the  nails  of  the  child.  If  the  top  of 
the  vesicle  is  destroyed,  or  most  of  the  compartments  are  opened, 
the  inflammation  is  commonly  increased,  considerable  suppuration 
occurs,  and  there  results  a  large,  irregular,  yellowish  scab,  consist- 
ing of  the  virus  mixed  with  desiccated  pus.  This  scab  is  entirely 
unreliable,  and  unfit  for  the  purpose  of  vaccination,  though  the 
protective  power  of  the  disease  is  not  diminished  by  injurj^  of  the 
vesicles,  even  if  it  is  totally  destroyed.  The  cicatrix  which  results 
from  extensive  injury  of  the  vesicle  is  apt  to  be  large,  and  with- 
out the  indented  points  which  characterize  the  normal  cicatrix. 

In  rare  cases,  when  the  inflammation  which  surrounds  the  vesi- 
cle is  intense  and  deep-seated,  suppuration  occurs  in  the  subjacent 


218  VACCINIA. 

cellular  tissue,  giving  rise  to  an  abscess.  This  abscess  is  commonly 
of  small  size,  Ijut  it  increases  the  frotfulness  and  constitutional 
disturbance  which  attend  vaccinia.  This  subcutaneous  suppvira- 
tion  is  believed  to  occur  most  frequently  in  those  who  have  a 
scrofulous  or  vitiated  state  of  system.  Inflammation  of  the  lym- 
phatic glands  of  the  axilla  I  have  spoken  of  as  not  infrequent  in 
vaccinia.  This  sometimes  proceeds  to  suppuration,  producing  an 
unpleasant,  though  not  serious,  complication. 

It  sometimes  happens  that  vesicles  appear  in  other  parts  besides 
the  points  where  the  virus  was  inserted.  These  supernumerary 
vesicles  commonly  occur  where  the  cuticle  has  been  removed  by 
scalds  or  injuries. 

Trousseau  relates  the  case  of  an  infant  whom  he  had  vaccinated. 
On  the  eleventh  day  he  was  astonished  to  find  twenty-seven  vac- 
cine pustules  on  the  face,  trunk,  and  limbs.  This  infant  had,  how- 
ever, before  the  vaccination,  a  simple  non-specific  eruption  over 
the  whole  body,  and  it  was  believed  that  it  had  produced  these 
vaccinations  by  transferring  the  lymph,  with  its  nails,  to  the 
various  parts  where  the  cuticle  was  denuded. 

It  is  not  unusual,  also,  to  observe  minute  papules  appearing  on 
parts  of  the  surface  simultaneously  with  or  soon  after  the  vesicle, 
and  in  a  few  days  declining.  These  seem  to  be  abortive  vaccine 
eruptions. 

One  of  the  most  serious  complications  is  erysipelas.  This  may 
occur  directly  from  the  operation,  or  from  the  inflammation  caused 
by  the  vesicle,  when  the  virus  possesses  no  deleterious  property ; 
and,  again,  it  may  result  from  some  unknown  element  in  the  virus. 
It  may  occur  immediately  after  the  operation,  when  it  commonly 
prevents  the  working  of  the  virus,  or  during  the  vesicular  or  pus- 
tular stage;  or,  again,  after  desiccation  and  separation  of  the  scab. 
I  have  observed  it  commencing  at  all  these  periods. 

Erysipelas,  occurring  as  a  complication  of  vaccinia,  is  invaria- 
bly referred  by  the  friends  to  the  virus  employed,  and  the  phy- 
sician who  has  had  the  misfortune  to  vaccinate  is  often  unjustly 
blamed.  In  many  of  these  cases  there  was  a  strong  predisposition 
to  erysipelas  at  the  time  of  the  vaccination,  and  the  operation  or 
the  inflammation  which  accompanied  the  normal  development  of 
the  vesicle  served  simply  as  an  exciting  cause.  Erysipelas  would 
occur  as  soon  from  a  non-specific  sore ;  indeed,  we  not  unfrequently 
are  called  to  cases  of  this  disease  in  young  children,  which  com- 
menced from  non-specific  sores  upon  the  genitals,  or  one  of  the 
limbs.     That  the  fault  is  not  in  the  virus  employed,  is  evident 


J 


ANOMALIES,    COMPLICATIONS,    AND    SEQUELS.  219 

from  tlic  fiict  that  otlier  children,  vaccinated  with  the  same,  have 
simple  uncomplicated  vaccinia. 

Sometimes,  on  the  other  hand,  the  cause  of  erysipelas,  whatever 
it  may  he,  exists  in  the  virus.  For  further  facts  in  reference  to 
this  suhject,  the  reader  is  referred  to  our  remarks  on  erysipelas. 

The  fact  is  established  by  many  observations  that  syphilis  is 
communicable  by  vaccination.  The  symptoms  of  it  may  not  appear 
till  vaccinia  has  terminated,  or  for  a  little  time  subsequently,  but 
it  then  constitutes  a  very  serious  sequel.  A  physician  of  this  city, 
well  known  in  this  community  as  skilful  in  the  diagnosis  and 
treatment  of  skin  diseases,  and  therefore  not  likely  to  be  mistaken 
as  regards  the  nature  of  the  diseases,  states  that  he  communicated 
syphilis  to  two  infants  by  vaccinating  with  the  same  scab.  Both 
had  the  characteristic  syphilitic  eruption.  Recently  (January, 
1868)  an  infant  was  brought  to  Prof.  Alonzo  Clark's  clinique,  in 
this  city,  having  syphilitic  rupia,  which,  in  the  opinion  of  the 
physicians  present,  was  undoubtedly  the  result  of  vaccination.  ' 

Trousseau  relates  the  case  of  a  young  woman,  eighteen  years 
old,  who  was  vaccinated  with  virus  taken  from  an  infant  appa- 
rently in  perfect  health.  The  vaccination  was  unsuccessful ;  but 
twenty-three  days  subsequently  his  attention  was  called  to  an 
eruption  which  had  appeared  in  two  places  on  the  woman's  arm, 
corresponding  with  the  points  where  the  virus  had  been  inserted. 
The  eruption  was  that  of  ecthyma,  which,  by  the  next  examina- 
tion, which  was  five  days  subsequently,  had  been  transformed  into 
rupia.  The  axillary  lymphatic  glands  were  tumefied  and  indo- 
lent, and,  finally,  roseola  appeared,  which  removed  all  doubts  as 
to  the  syphilitic  character  of  the  disease.  There  was  syphilitic 
infection,  which  first  manifested  itself  in  the  points  where  vacci- 
nation had  been  performed  [Article  de  la  Vaccine).  It  is  not  ascer- 
tained in  Prof.  Clark's  case,  nor  is  it  stated  in  Trousseau's,  whether 
the  lymph  or  scab  was  employed  for  vaccination ;  but  it  is  proba- 
ble that  the  danger  of  syphilitic  infection  is  much  greater  from 
the  scab  than  from  the  lymph,  on  account  of  the  amount  of  animal 
matter  which  it  contains. 

The  vesicle  in  genuine  vaccinia  is  sometimes  very  small,  not 
having  a  diameter  of  more  than  two  lines.  Occasionally  the  de- 
velopment of  the  vesicle  is  retarded.  It  does  not  appear  till  two 
or  three  days  later  than  the  usual  time,  or  even  a  longer  period. 

Vaccinia  is  modified  by  certain  diseases.  It  is  arrested  by 
measles  and  scarlet  fever,  pursuing  its  course  after  the  subsidence 
of  the  exanthem.     On  the  other  hand,  it  arrests  the  paroxysmal 


220  VACCIXIA. 

cough  of  pertussis,  which  returns  when  the  pock  begins  to  desic- 
cate. Eczematous  eruptions  sometimes  occur  after  vaccinia,  as 
they  often  do  after  the  other  eruptive  fevers ;  or,  if  ah-eadj  pre- 
sent, they  may  be  aggravated. 

Subsequent  Vaccinations. 

A  second  vaccination,  performed  prior  to  the  ninth  day  after  the 
first  vaccination,  is  successfuh  A  genuine  vaccine  eruption  results, 
which  is  smaller  the  more  advanced  the  primary  disease.  This 
second  eruption  overtakes  the  first.  On  the  ninth  day  the  suscep- 
tibility to  vaccinia  is,  in  most  cases,  lost ;  so  that  vaccination  per- 
formed on  the  tenth,  or  subsequent  days,  is  unsuccessful. 

As  a  rule,  a  zymotic  disease  occurs  only  once  in  the  same  indi- 
vidual. Vaccinia  is  an  exception.  In  most  cases,  after  a  few 
years,  it  can  be  produced  a  second  time ;  and  cases  of  a  third  or 
fourth  successful  vaccination,  at  intervals  of  a  few  years,  are  not 
uncommon.  ISTow,  subsequent  cases  of  vaccinia  dift'er  from  the 
first,  which  has  been  described  above.  The  period  of  incubation 
is  shorter,  and  the  vesicular,  pustular,  and  desiccative  stages  suc- 
ceed each  other  more  rapidly,  so  that  the  whole  period  of  the  disease 
is  less.  The  variation  from  the  appearance  and  course  of  the  first 
vesicle  is  proportionate  to  the  degree  of  protection  which  the  first 
vaccination  still  aftbrds,  both  as  regards  smallpox  and  vaccinia. 
If  several  years  have  elapsed  since  the  first  vaccination,  and  the 
protective  power  which  it  aftbrded  is  nearly  lost,  the  second 
vaccinia  differs  but  little  from  the  first.  If,  on  the  other  hand,  the 
first  vaccination  still  atfords  nearly  complete  protection,  the  result 
of  the  second  is  slight;  the  eruption  is  insignificant,  lacking  the 
characteristic  appearance  of  the  vaccine  vesicle,  resembling  a  com- 
mon sore,  and  disappearing  within  a  week.  It  is  accompanied  by 
no  inflamed  areola,  and  by  no  constitutional  disturbance. 

Vaccination  often  produces  no  result.  This  is  sometimes  due  to 
the  fact  that  the  lymph  or  scab  employed  is  useless.  It  has  spoiled 
by  keeping,  or  never  has  been  good.  In  other  cases  it  is  due  to  a 
lack  of  susceptibility  in  the  person.  Some  take  vaccinia  with  diffi- 
culty, and  only  after  several  vaccinations;  just  as  children, though 
fully  exposed,  often  fail  to  take  measles  or  scarlet  fever,  on  account 
of  a  condition  of  the  system  which  prevents  the  reception  of  the 
virus,  or  antagonizes  and  controls  its  action.  In  some  instances, 
after  vaccination,  an  eruption  is  produced,  which  may  or  may  not 
be  genuine;  but  it  immediately  becomes   purulent,  and   is   soon 


PROTECTION    FROM    VACCINATION.  221 

broken.  A  large,  yellow,  uneven  scab  results,  Laving  none  of  the 
appearance,  and  containing  little  or  none  of  the  vaccine  virus.  This 
scab,  as  well  as  the  liquid  matter  which  preceded  the  formation  of 
the  scab,  is  utterly  useless  for  the  purpose  of  vaccination,  and,  if  so 
employed,  will  probably  cause  a  sore  from  its  irritating  effect,  but 
not  of  a  specific  character.  If,  in  place  of  the  true  vaccine  vesicle, 
the  eruption  presents  the  appearance  which  I  have  described, 
namely,  that  of  a  pustule,  soon  breaking,  and  forming  a  large, 
irregular,  yellowish  scab,  the  vaccinia — if  it  is  correct  so  to  desig- 
nate it — must  be  considered  spurious.  A  sore  has  been  produced 
by  the  animal  matter  which  was  employed  in  the  vaccination  along 
with  the  virus,  which  has  modified  the  action  of  the  virus,  and 
probably  has  rendered  it  useless  as  a  means  of  protection ;  or  there 
may  have  been  no  virus  inserted  with  this  animal  matter.  The 
physician  should  in  such  cases  insist  on  a  second  vaccination. 

Cases  like  the  above  are  of  frequent  occurrence,  and  the  parents 
of  the  child  are  often  satisfied  with  the  result.  They  see  an  erup- 
tion following  the  vaccination,  accompanied  by  considerable  inflam- 
mation, and  leaving  a  cicatrix.  Unless  undeceived  by  the  physi- 
cian, they  are  apt  to  remain  in  the  belief  of  the  child's  security, 
until,  perhaps,  it  takes  smallpox.  Such  cases,  obviously,  tend  to 
diminish  the  confidence  which  the  public  should  have  in  vaccina- 
tion as  a  means  of  protection  from  smallpox,  and  on  account  of 
their  frequent  occurrence  it  is  important  in  all  cases  that  the  phy- 
sician should  see  the  result  of  his  vaccination.  It  has  been  pro- 
posed, as  a  means  of  determining  the  genuineness  of  the  vaccinia,  , 
to  revaccinate  when  the  eruption  begins,  and  if  the  first  is  genu- 
ine, the  second  will  overtake  it.  This  is  called  Brice's  test ;  but  it 
is  not  necessary,  since  the  physician,  familiar  with  the  appearance 
of  the  true  vesicle,  can  determine  at  once  its  genuineness  by  the 
sight. 

Protection  from  Vaccnation— Revaccination. 

It  was  believed  by  the  early  advocates  of  vaccination  that  the 
general  performance  of  this  operatiort  would  soon  eradicate  small- 
pox from  the  community,  so  that  it  would  be  regarded  as  a  disease 
of  the  past,  rather  than  of  the  present  time.  This  result,  however, 
is  not  achieved.  As  a  rule,  the  greater  the  benefit  of  any  measure 
designed  to  ameliorate  the  condition  of  mankind,  the  greater  and 
more  numerous  are  the  obstacles  which  diminish  its  eflfectiveness. 
Science  is  full  of  examples  of  this.     Fortunately  these  obstacles, 


222  VACCINIA. 

as  regards  vaccination,  are  not  such  as  to  impair  the  confidence  of 
physicians  in  its  protective  power,  and  it  is  not  too  much  to  expect 
that  this  simple  operation  will  yet  be  the  means  of  rendering  small- 
pox a  disease  almost  unknown,  unless  in  its  modified  form. 

Vaccination  should  be  performed  in  the  first  year  of  life.  In 
the  country,  where  there  is  little  danger  of  exposure  to  smallpox, 
it  may  be  deferred  till  the  age  of  ten  or  twelve  months.  In  the 
city,  on  the  other  hand,  where  there  is  constant  intercourse  of 
people,  and  where  contagious  diseases  are  often  contracted  without 
its  being  known  when  exposure  occurred,  an  earlier  vaccination  is 
advisable.  Some  physicians  recommend  performance  of  the  opera- 
tion as  early  as  the  age  of  four  to  six  weeks.  The  objection  to 
this  is,  that  if  erysipelas  occur,  so  young  an  infant  is  apt  to  perish 
from  it,  whereas  an  infant  three  or  four  months  old  ordinarily 
recovers.  For  this  reason  I  believe  that  the  most  suitable  ao;e  is 
about  four  months  for  the  city  infant,  in  ordinary  times ;  but  if 
smallpox  is  epidemic,  vaccination  should  be  performed  at  an  earlier 
age.  I  have  vaccinated  even  the  new-born  infant  when  smallpox 
had  broken  out  in  adjoining  apartments. 

Vaccinia  usually  extinguishes,  for  a  time,  the  susceptibility  to 
smallpox.  According  to  M.  Gintrac,  varioloid  does  not  occur 
A\Hthin  two  years  in  those  who  have  been  vaccinated.  It  may, 
however,  in  exceptional  instances,  occur  in  a  mild  form  within  a  few 
months  after  vaccination.  The  protection  afforded  by  vaccination 
gradually  diminishes  by  time,  but  it  does  not,  probably,  as  a  rule, 
cease  entirely.  Varioloid,  however,  occurring  thirty  or  forty  years 
after  a  successful  vaccination,  is  apt  to  be  severe,  and  it  may  even 
be  fatal,  showing  that  it  has  been  but  slightly  modified.  In  other 
eases,  even  after  so  long  an  interval,  the  symptoms  present  a  degree 
of  mildness  which  indicates  that  the  protective  power  of  the  vacci- 
nation is  not  entirely  lost. 

If  a  second  vaccination  is  practised  soon  after  the  scab  from  the 
first  vaccination  has  fallen,  it  will  usually  produce  no  result,  but  in 
other  cases  it  gives  rise  to  a  little  redness,  swelling,  and  induration, 
which  show  that  vaccinia  has  been  reproduced,  though  in  a  very 
mild  and  insignificant  form.  It  is  probable  that  in  these  cases 
varioloid  might  also  occur  by  exposure,  though  with  a  mildness 
corresponding  with  that  of  the  vaccinia.  The  longer  the  period 
after  the  first  vaccination,  the  greater  the  number  of  those  in  whom 
a  second  vaccination  is  effective,  and,  as  has  already  been  intimated, 
the  greater  also  the  liability  to  the  variolous  disease  if  a  second 
vaccination  is  not  performed.     It  is  recommended,  therefore,  to 


SELECTION    OF    VIRUS.  223 

perform  a  second  vaccirmtion  not  iater  than  the  sixth  or  eighth 
year,  and  again  in  cliiklhood.  And  if  smallpox  is  epidemic,  it  is 
proper  to  vaccinate  all  who  have  not  heen  vaccinated  within  three 
or  four  years. 

Selection  of  Virus. 

The  l^aiiph  is  preferable  to  the  scab  for  vaccination,  provided 
that  it  can  be  obtained  fresh.  The  scab  is  more  easily  preserved, 
and,  therefore,  if  the  lymph  and  scab  are  old,  the  latter  is  to  be 
preferred.  The  lymph  should,  if  the  vesicle  is  sufficientl}^  de- 
veloped, be  taken  on  the  fifth  day.  It  may  also  be  taken  on  the 
sixth,  seventh,  or  even  eighth  day,  provided  that  the  areola  has  not 
formed.  The  lymph  of  the  fifth  day  acts  with  greater  energy, 
though  that  of  the  sixth  or  seventh  day  is  not  much  inferior. 
Lymph  obtained  after  the  formation  of  the  areola  is  less  eflicient, 
though  it  may  communicate  the  genuine  disease. 

There  is  no  mode  of  vaccination  so  reliable  as  the  use  of  lymph, 
taken  directly  from  the  arm  and  immediately  inserted — the  arm  to 
arm  vaccination.  Lymph  can  be  preserved  for  a  few  days  on  a  flat- 
tened surface  of  whalebone,  or  the  segment  of  a  quill ;  the  former 
I  prefer,  and  if  employed  within  a  week,  it  will  usually  communi- 
cate vaccinia.  Lymph  may  be  preserved  a  longer  period  between 
two  surfaces  of  glass,  but  the  best  way  of  preserving  it  is  in  capil- 
lary glass  tubes.  The  end  of  the  tube  is  placed  within  the  vesicle, 
and  the  lymph  ascends  by  capillary  attraction.  When  a  sufficient 
quantity  is  received,  the  ends  are  sealed,  by  holding  them  for  a 
moment  in  a  flame.  Care  is  requisite  in  doing  this,  so  as  not  to 
heat  the  lymph,  as  it  is  spoiled  by  a  temperature  much  above  the 
body.  AVhen  the  lymph  is  used,  the  ends  of  the  tube  are  broken, 
and  by  blowing  gently  through  it,  a  sufiicient  quantity  is  received 
on  the  point  of  a  lancet. 

If  the  scab  is  genuine,  it  presents  a  dark-brown  or  mahogany 
color,  and  has  a  circular,  oval,  or  at  least  a  rounded  form;  it  is 
firm,  or  compact,  and  has  a  lustre.  Soft,  j-ellowish,  and  irregular 
scabs  are  not  genuine,  and  those  of  a  dull  appearance,  or  without 
lustre,  have  usually  spoiled  in  the  keeping.  It  is  the  belief  of 
many  that  the  vaccine  virus  gradually  becomes  weaker  by  passing 
successively  through  the  human  system  (Condie,  American  Jouryial 
of  the  Medical  Sciences,  April,  1865),  and  that  therefore  different 
specimens  of  virus  work  with  different  energy,  according  to  the 
degree  of  removal  from  the  cow.  To  what  extent  this  view  is  cor- 
rect is  not  fully  ascertained,  but,  certainly,  if  the  virus  employed 


224:  VARICELLA. 

continues  to  produce  a  small  vesicle,  and  attended  only  by  little 
inflammation,  there  is  reason  to  believe  that  the  protection  which 
it  imparts  is  less  than  that  from  virus  which  works  with  greater 
energy,  and  it  should  be  exchanged  for  such.  The  scab  is  best  pre- 
served in  soft  beeswax,  which  excludes  the  air,  and  it  should  be 
kejDt  in  a  cool  place. 


CHAPTER   V. 

VARICELLA. 


Varicella,  chickenpox  or  swinepox,  is  the  shortest  and  mildest 
of  the  eruptive  fevers.  It  is  highly  infectious,  so  that  few  children 
escape  who  are  exposed  to  it.  Its  period  of  incubation  is  from  fif- 
teen to  seventeen  days.  It  is  not  inoculable,  or  at  least  those  who 
have  attempted  to  inoculate  with  the  lymph  of  varicella  have 
failed.  I  endeavored  to  communicate  the  disease  in  this  way  some 
years  ago,  but  without  result.  It  attacks  the  same  individual  but 
once,  and  it  occurs  as  an  epidemic.  It  has  been  thought  by  some 
to  prevail  most  immediately  before,  during,  or  after  epidemics  of 
smallpox,  and  it  has  been  conjectured  that  it  is  a  modified  form  of 
variola,  and  hence  its  name,  which  signifies  little  variola.  This 
idea  is,  however,  entertained  by  few,  and  it  is  opposed  by  the  fol- 
lowing facts.  Varicella  may  occur  after  variola,  or  variola  after 
varicella,  without  any  modification,  and  the  two  diseases  are  very 
dissimilar  as  regards  gravity  of  symptoms  and  duration.  The  va- 
riolous disease,  whether  smallpox  or  varioloid,  often  occurs  in  the 
adult;  varicella,  on  the  other  hand,  is  a  disease  of  infancy  and 
childhood.  Professor  Flint  states  that  he  has  observed  it  in  the 
adult,  but  its  occurrence  at  this  period  of  life  is  rare.  Moreover 
varicella  and  variola  have  been  known  to  occur  simultaneously  in 
the  same  individual.  Such  a  case  was  reported  by  M.  Delpech,  in 
a  memoir  published  in  1845. 

Symptoms. — Varicella  usually  commences  with  such  symptoms  as 
usher  in  ordinary  mild  febrile  attacks,  namely,  headache,  languor, 
chilliness,  and  sometimes  aching  in  the  back  and  limbs.  Fever 
supervenes,  which  is  usually  moderate,  the  pulse  rising  perhaps  to 
100  or  112,  and  the  thermometer  showing  an  increase  of  tempera- 
ture, but   less  than  occurs  in  the  other  eruptive  fevers.     These 


DIAGNOSIS.  225 

symptoms,  which  precede  the  eruption,  are  sometimes  absent,  or 
are  so  mild  as  to  escape  notice.  The  fever  usually  ceases  on  the 
second  day,  but  it  may  return  on  the  following  night.  The  appe- 
tite is  rarely  lost,  and  most  children  continue,  more  or  less,  at  their 
amusements. 

The  eruption  commences  in  about  twenty-four  hours,  appearing 
as  small  red  points,  first  over  the  trunk,  and  soon  afterwards  over 
the  face  and  limbs.  These  points,  which  are  at  first  minute  pap- 
ules, become  vesicular  in  the  course  of  a  few  hours.  The  occur- 
rence of  the  vesicular  stage  is  nearly  simultaneous  on  all  parts  of 
the  surface.  The  vesicles  lack  the  hard,  indurated  base  of  the 
variolous  eruption,  though  they  are  sometimes  surrounded  by  a 
faint  zone  of  redness.  They  differ  also  from  the  variolous  erup- 
tion in  the  absence  of  umbilication,  and  in  irregularity  of  shape. 
Some  are  small  and  acuminate,  some  hemispherical,  and  of  medium 
size,  and  others  oval  or  elongated,  and  of  large  size.  The  inflam- 
mation is  quite  superficial,  not  involving  the  subcutaneous  tissue, 
and  scarcely  affecting  the  deepest  layer  of  the  skin.  • 

The  vesicles  vary  in  size  from  the  diameter  of  half  a  line  to 
that  of  even  three  lines.  They  occasionally  give  rise  to  slight 
itching.  On  the  second  day  of  the  eruption,  or  third  of  the  dis- 
ease, the  vesicles  are  still  fully  developed,  their  liquid  contents 
being  nearly  transparent.  At  the  close  of  this  day  the  liquid  be- 
gins to  be  somewhat  cloudy,  and  its  absorption  commences.  On 
the  fourth  day  of  the  disease  desiccation  progresses  rapidly,  and  by 
the  fifth  the  liquid  has  for  the  most  part  disappeared,  and  there 
results  a  scab,  small  and  thin,  of  a  yellowish-brown  color.  The 
scabs  are  soon  detached,  the  redness  which  indicated  their  seat  dis- 
appears, the  epiderm  which  had  been  raised  and  removed  by  the 
eruption  is  reproduced  in  its  normal  state,  and  in  a  few  days  all 
evidence  of  varicella  is  effaced.  A  cicatrix  occasionally  results, 
but  it  is  due  not  to  the  simple  varicellar  eruption,  but  to  a  sore 
produced  from  the  eruption  by  the  scratching  of  the  child. 

The  number  of  vesicles  varies  considerably  in  different  cases. 
They  are  never,  so  far  as  I  have  observed,  confluent ;  but  they  are 
sometimes  so  abundant  in  young  children  that,  if  the  disease  were 
variola,  it  would  be  called  severe  discrete. 

Diagnosis. — Obviously  the  only  diseases  with  which  varicella  is 
liable  to  be  confounded  are  such  as  present  vesicles  at  some  stage 
of  their  course.  From  the  local  vesicular  eruptions  this  disease  is 
diagnosticated  by  the  fact  that  the  vesicles  appear  on  all  parts  of 
the  surface.  It  is  sometimes  mistaken  for  variola  or  varioloid,  or 
15 


226  VARICELLA. 

vice  versd — a  mistake  very  damaging  to  the  reputation  of  the  phy- 
sician. The  points  of  differential  diagnosis  are  the  symptoms  of 
invasion — severe,  and  lasting  three  or  four  days  in  the  one  ;  mild, 
and  continuing  only  one  day  in  the  other — an  eruption  passing 
slowly  through  its  stages  from  the  papulae  to  the  pustulse,  umbili- 
cated,  with  circular,  raised,  and  inflamed  base,  appearing  first  on 
the  face  and  neck,  and  not  till  a  day  later  on  the  legs,  in  the  one 
disease ;  while  in  the  other  the  evolution,  shape,  and  course  of 
the  eruption,  as  described  above,  are  materially  different.  By 
proper  attention  to  these  distinctive  features  it  is  rarely  difficult  to 
diao-nosticate  the  two  diseases. 

The  PROGNOSIS  in  varicella  is  always  favorable.  It  does  not,  of 
itself,  endanger  life,  nor  seriously  incommode  the  patient ;  nor  does 
it  give  rise  to  complications  nor  sequels.  The  treatment,  there- 
fore, is  the  simplest  possible.  Mild  diet,  and  a  laxative,  may  be 
prescribed  during  the  febrile  period ;  but  nothing  further  is  re- 
quired. 


SECTION  HI. 

NON-ERUPTIVE  CONTAGIOUS  DISEASES. 


CHAPTER   I. 

DIPHTHERIA. 


The  term  diphtheria,  or  cliphtheritis,  is  apj^lied  to  a  blood  disease, 
which,  like  measles  or  scarlet  fever,  has  a  local  inflammatory  mani- 
festation. The  inflammation  occurs  on  mucous  surfaces,  and  the 
skin  when  denuded  of  its  epidermis,  and  is  attended  by  fibrinous 
exudation.  Diphtheria  has  of  late  years  attracted  much  attention 
on  the  part  of  physicians  as  well  as  the  public,  on  account  of  its 
epidemic  visitation  in  many  diflerent  localities,  and  the  great  mor- 
tality which  has  uniformly  attended  it.  It  has,  of  late  years,  been 
the  subject  of  frequent  discussion  in  the  medical  societies  of  Europe 
and  this  country,  and  the  journals  during  this  period  contain  nume- 
rous reports  of  cases,  and  many  monographs  designed  to  elucidate 
its  nature.  Though  there  is  much  that  is  still  obscure  in  reference 
to  diphtheria,  the  great  interest  which  it  has  awakened  has  led  to 
a  better  understanding  of  its  nature,  and  a  more  judicious  use  of 
therapeutic  agents. 

Diphtheria  presents  itself  under  two  forms,  primary  and  second- 
ary. The  primary  is  more  common.  The  secondary  is  usually  a 
complication  or  a  sequel  of  scarlet  fever  or  measles,  or  more  rarely 
of  typhoid  fever,  and  this  form  is,  therefore,  chiefly  observed  when 
these  diseases  are  epidemic.  The  two  forms  are  identical  in  nature, 
symptoms,  and  appearance ;  the  difference  consisting  in  the  fact 
that  diphtheria,  when  occurring  as  a  complication  or  sequel,  is  more 
serious,  and  apt  to  be  fatal.  Ordinarilj^  this  secondarj^  form  com- 
mences before  the  primary  aflfection  abates,  so  that  there  is  no  inter- 
mission between  the  two  pathological  states.  The  fevers  which  we 
have  mentioned  probably  predispose  to  diphtheria,  not  only  from 
the  affinity  which  exists  between  them  and  that  disease  in  conse- 


228  DIPHTHERIA. 

quence  of  their  zymotic  nature,  but  from  the  fact  that  diphtheria 
is  more  apt  to  occur  if  there  is  pre-existing  faucial  inflammation. 
In  both  measles  and  scarlet  fever  the  pharyngitis  is  still  present, 
and  in  many  has  not  begun  to  decline  when  the  diphtheria  com- 
mences. Thus,  in  a  case  occurring  in  my  practice,  death  resulted 
from  diphtheria  eight  days  after  the  commencement  of  the  rubeo- 
lous  eruption,  the  pseudo-membrane  being  first  observed  while  the 
rash  was  still  present. 

Anatomical  Characters. — Before  considering  the  anatomical 
changes  which  occur  in  diphtheria,  it  is  well  to  state  what  cases 
I  consider  to  be  diphtheritic.  When  this  disease  is  prevailing, 
most  observers  have  remarked  the  frequent  occurrence  of  pharyn- 
gitis without  the  pseudo-membrane ;  and  some  hold  that  these 
cases,  as  they  seem  to  be  due  to  the  epidemic  influence,  should  be 
called  diphtheritic.  But  this  would  only  lead  to  confusion.  We 
might  with  equal  propriety  consider  the  sore-throat,  which  many 
physicians  experience  when  attending  cases  of  scarlet  fever,  as  that 
disease.  The  term  diphtheria  should  be  limited  to  those  cases  in 
which  the  pharyngitis  or  other  mucous  inflammation  is  attended 
by  the  formation  of  patches  of  pseudo-membrane,  for  it  is  only  by 
the  presence  of  these  that  we  are  enabled  to  distinguish  diphtheria 
from  simple  inflammation,  the  constitutional  from  the  local  disease. 
By  employing  the  term  diphtheria  with  great  latitude,  some  ob- 
servers have  rendered  the  statistics  of  this  disease,  which  they 
have  published,  almost  useless. 

The  first  departure  from  the  state  of  health  doubtless  occurs  in 
the  blood,  but  the  exact  changes  which  this  fluid  undergoes,  as  in 
other  contagious  diseases,  have  not  been  fully  ascertained.  I  shall 
hereafter  describe  the  appearance  of  the  blood,  as  ascertained  at  the 
autopsies  of  those  who  have  died  of  this  disease.  Immediately 
upon  the  invasion  of  diphtheria,  redness  is  observed  on  some  part 
of  the  faucial  mucous  membrane,  usually  that  part  covering  a  tonsil 
or  in  its  immediate  vicinity.  The  inflammation  thus  commencing 
as  a  faint  blush,  rapidly  extends.  The  color  of  the  inflamed  sur- 
face is  sometimes  a  deep,  bright  red,  almost  like  arterial  blood ;  in 
others  it  is  dusky  red,  which  indicates  a  vitiated  state  of  the  blood, 
and  is  an  unfavorable  prognostic  sign.  The  dusky-red  appearance 
is  most  common  in  the  secondary  form.  In  a  large  proportion  of 
cases,  in  the  course  of  a  few  hours  almost  the  entire  faucial  surface 
is  involved  in  the  inflammatory  process.  The  mucous  membrane 
of  this  part  is  thickened  and  softened,  its  follicles  tumefied  and 
actively  secreting,  and  there  is  more  or  less  submucous  infiltration. 


ANATOMICAL    CHARACTERS.  229 

The  intensity  as  well  as  the  extent  of  the  phlegmasia  varies,  liow- 
ever,  considerably  in  different  patients.  In  a  mild  attack  it  is  often 
limited  to  a  part  of  the  fauces,  and  in  these  cases  there  are  few  ex- 
ceptions to  the  rule  that  the  tonsillar  portion  is  affected,  the  redness 
gradually  fading  away  in  the  healthy  membrane  beyond.  There 
is  swetling  of  the  tonsils  themselves,  so  that  often  they  nearly  touch 
each  other.  If  the  pharyngitis  is  general,  the  passage  through  this 
portion  of  the  digestive  tube  is  greatly  diminished,  but  in  most 
cases  no  more,  and  in  many  children  not  so  much  as  in  severe 
simple  pharyngitis. 

"Within  a  day,  and  usually  within  a  few  hours,  from  the  com- 
mencement of  the  inHammation,  a  small  semi-transparent  and 
almost  diffluent  point  is  observed  upon  the  part  most  inflamed,  or 
a  thin  film,  of  little  importance,  did  the  disease  stop  here,  but  very 
significant  as  a  diagnostic  sign,  and  as  a  forerunner  of  what  is  to 
happen.  This  substance,  which  is  fibrinous,  gradually  becomes 
firmer,  and  at  the  same  time  thicker  and  broader,  presenting  a 
grayish  or  a  grayish-white  color.  Sometimes  different  points  or 
patches  are  observed,  which  extend  and  coalesce  so  that  the  fauces 
are  almost  entirely  concealed  from  view.  The  pseudo-membrane 
is  closely  attached  to  the  mucous  surface,  which  it  penetrates,  be- 
coming firm,  and  not  easily  detached.  Attempts  to  separate  it 
often  lacerate  the  engorged  capillaries,  producing  a  free  flow  of 
blood.  It  does  not  ordinarily  attain  a  greater  thickness  than  one- 
eighth  to  one-sixth  of  an  inch.  I  have  seen  it,  however,  not  far 
from  one-third  of  an  inch  thick. 

The  same  pseudo-membrane  is  often  firmer  in  one  part  than 
another,  the  outer  and  central  portions  being  more  compact  and 
tough  for  a  time  than  that  underneath,  which  is  more  recent,  and 
in  which  there  is  less  fibrillation.  After  a  few  days,  however, 
decomposition  commences,  and  then  that  which  was  first  formed 
becomes  softer  than  the  more  recent  production.  When  this 
occurs,  the  color  of  the  exudation  changes  from  a  whitish  or  a 
grayish-white  to  a  dirty  brown,  and  its  exposed  surface  is  uneven 
and  jagged  from  the  partial  separation  of  shreds  and  fibres. 

The  escape  of  the  liquor  sanguinis  from  the  engorged  vessels 
diminishes  somewhat  the  turgescence  of  the  inflamed  tissue.  If 
this  is  considerable,  the  pseudo-membrane  often  sinks  below  the 
level  of  the  surrounding  surface,  producing  an  appearance  very 
much  like  that  of  an  ulcer,  or  even  of  gangrene.  Though  there  is  no 
loss  of  substance  in  this  particular  state  of  the  surface,  it  does,  how- 
ever, often  occur,  being  produced  by  the  presence  and  contraction 


230  DIPHTHERIA. 

of  the  fibrin  with  which  it  is  infiltrated.  Sometimes  the  pseudo- 
membrane  has  a  reddish  tinge.  This  is  due  to  rupture  of  the  capil- 
laries, and  the  escape  of  the  blood  corpuscles.  It  occurs  in  those 
cases  in  which  the  inflammation  is  intense,  and  the  capillaries  are 
greatly  engorged.  Sometimes  the  lower  part  of  the  exudation  is 
blood-strained,  while  the  exposed  surface  has  the  usual  grayish- 
white  hue.     (Appendix  C.) 

During  the  height  of  the  inflammation  it  is  astonishing  often 
to  see  with  what  rapidity  the  diphtheritic  membrane  returns, 
when  removed  by  force.  A  few  hours  often  sufiice  to  restore  it  as 
firm  and  extensive  as  before  the  interference.  If  the  exudation  is 
examined  with  the  microscope  as  soon  as  it  aj^pears  upon  the 
faucial  surface,  it  is  seen  to  consist  largely  of  cells,  to  wit,  plastic 
nuclei  and  pus  cells  mixed  with  epithelia ;  with  these  elements,  we 
find  amorphous  matter,  and  ordinarily  delicate  interlacing  fibrillse. 
Subsequently  fibrillation  is  more  complete,  and  the  false  membrane 
consequently  more  firm  and  resisting.  In  feeble  children  fibrilla- 
tion is  sometimes  lacking,  or  is  so  slight  as  not  to  be  observed  with 
the  microscope.  In  these  cases  the  pseudo-membrane  is  cellular 
and  amorphous,  and  is  easily  detached.  Such  was  its  microscopic 
character  in  a  case  which  occurred  in  the  Kursery  and  Child's 
Hospital  of  this  city;  the  inflammatory  product  in  this  patient 
covered  the  mucous  membrane  of  the  stomach,  as  well  as  those 
parts  which  are  commonly  the  seat  of  it.  This  case  I  shall  allude 
to  again. 

By  the  microscope  we  are  able  to  detect,  in  some  instances,  a 
confervoid  growth  in  or  upon  the  pseudo-membrane.  This  is  com- 
monly the  oidium  albicans,  or  a  plant  closely  allied  to  it,  or  the 
lepothrix  buccalis,  and  its  presence  has  led  some  observers  to  think 
that  the  primary  and  essential  part  of  the  adventitious  formation 
is  parasitic.  Fortunately,  so  erroneous  an  idea  of  the  pathology* 
of  diphtheria  is  easily  disproved,  for  in  most  cases  of  this  disease 
no  vegetable  growth  can  be  detected.  The  pseudo-membrane  does, 
however,  constitute  a  favorable  nidus  for  the  growth  of  confervse, 
like  any  animal  matter  of  low  vitality,  or  of  no  vitality,  and  hence 
the  cause  of  their  appearance  upon  the  fauces  in  this  disease. 
Confervae  sometimes  also  grow  upon  the  inflamed  surface  in  simple 
pharyngitis,  producing  an  appearance  which  simulates  closely  that 
of  the  diphtheritic  membrane,  and  it  is  apt  to  be  mistaken  for  it 
unless  its  true  character  is  determined  by  the  microscope.  As 
an  example  of  the  simple  inflammation  simulating  the  pseudo- 
membranous, may  be  mentioned  the  case  of  a  little  girl  in  this 


ANATOMICAt    CHARACTERS.  231 

city,  whom  I  was  called  to  attend  when  diphtheria  was  prevailing. 
There  was  in  this  patient  intense  faucial  inflammation,  with  a 
grayish-white  substance  like  fibrin  over  one  tonsil.  This  sub- 
stance, examined  with  the  microscope,  was  found  to  consist  of  the 
lepothrix  buccalis,  with  epithelia  and  amorphous  matter.  The 
disease,  which  was  speedily  cured,  would  without  microscopic 
examination  have  passed  for  diphtheria. 

In  favorable  cases  the  false  membrane  is  detached  in  a  few  days, 
and  is  either  expectorated  or  swallowed  with  the  ingesta.  Its 
separation  is  promoted  by  the  secretions  underneath,  especially 
by  pus,  which  is  formed  in  abundance  between  it  and  the  surface 
on  which  it  lies  and  which  it  penetrates.  In  many,  perhaps  a 
majority  of  cases,  however,  it  does  not  separate  in  mass,  but  by 
progressive  liquefaction.  A  little  less  of  the  pseudo-membrane  is 
observed  at  each  visit,  until  it  entirely  disappears.  Such  are  the 
appearance,  character,  and  history  of  the  pseudo-membrane  in  this 
disease.  Its  common  seat  is  upon  the  fauces,  and  in  mild  cases 
it  is  ordinarily  found  there  alone.  Unfortunately,  the  nature  of 
diphtheria  as  a  blood  disease  renders  all  the  mucous  surfaces  liable 
to  be  attacked  by  the  inflammation,  and  therefore  in  severe  cases, 
and  even  in  cases  of  moderate  severity,  we  often  find  this  product 
elsewhere,  as  well  as  upon  the  fauces,  and  in  localities  where,  from 
its  mechanical  efi'ect,  it  greatly  increases  the  danger,  and  even 
compromises  life.  The  mucous  membrane  of  the  nostrils,  mouth, 
larynx,  trachea,  oesophagus,  stomach,  conjunctiva,  vagina,  and  even 
the  delicate  lining  of  the  external  ear,  are  at  times  the  seat  of 
diphtheritic  inflammation,  with  the  characteristic  product.  If  the 
exudation  occur  in  the  larynx,  or  air-passages  below  the  larynx, 
we  have  the  phenomena  and  result  of  true  croup;  if  upon  a  surface 
concerned  in  the  digestive  process,  this  function  is  more  or  less 
interfered  with.  I  have  already  alluded  to  a  case  which  occurred 
in  the  Nursery  and  Child's  Hospital  of  this  city,  in  which  patient 
the  surface  of  the  stomach  was  almost  completely  lined  with  the 
diphtheritic  formation,  so  that  the  function  of  this  organ  was  appa- 
rently nearly  or  quite  abolished.  The  occurrence  of  the  pseudo- 
membrane  in  the  nares  is  common,  and  is  attended  by  the  discharge 
of  thin  mucus  and  pus ;  but  though  inconvenient  to  the  patient, 
its  presence  in  this  situation  is  not  dangerous,  except  in  the  nursing 
infant,  in  whom  it  interferes  more  or  less  with  lactation.  The  thin 
irritating  discharge  produces  excoriation  around  the  nostrils  and 
upon  the  upper  lip. 

Diphtheria  is  ordinarily  attended  by  inflammation  of  the  cervical 


232  DIPHTHERIA. 

glands,  wliicli  lie  in  the  connective  tissue  behind  and  below  the 
angle  of  the  lower  jaw,  and  in  cases  of  great  severity  this  tissue  is 
also  involved,  becoming  swollen  and  indurated.  The  adenitis  begins 
early,  and  corresponds  in  degree  with  the  pharyngeal  inflammation. 
It  is  never  or  very  seldom  as  great  in  simple  pharyngitis  as  in  this 
disease.  Great  external  swelling  of  the  neck,  indicating  a  grave 
form  of  diphtheria,  is,  therefore,  to  be  regarded  as  an  unfavorable 
sign.  The  inflamed  glands  and  connective  tissue  are  hard  and  tender 
on  pressure,  but  they  less  frequently  suppurate  than  when  similarly 
afiiected  in  scarlet  fever.  I  have  known  but  two  instances  of  sup- 
puration, the  pus  in  both  escaping  externally  through  the  skin. 

The  exudation  occurs  also  on  the  cutaneous  surface  when  blis- 
tered or  abraded,  and  upon  the  edges  of  the  wound  produced  by 
tracheotomy.  This  fact  is  interesting,  as  showing  the  pervading 
character  of  the  diphtheritic  virus. 

Bronchitis  is  often  present  in  diphtheria,  with  or  without  fibri- 
nous exudation  in  the  tube.  Pneumonia  is  also  so  often  present, 
that  its  occurrence  is  somethins;  more  than  mere  coincidence. 

In  those  who  have  died  of  diphtheria  the  blood  has  been  found 
of  a  dark-red  color,  sometimes  almost  brown.  Its  appearance  has 
been  compared,  on  account  of  its  color,  to  prune-juice.  This  color 
is  due,  partly,  in  those  who  have  died  from  apncea  in  consequence 
of  exudation  in  the  larynx,  to  imperfect  oxygenation  of  the  blood, 
but  it  is  also  due  to  the  malignant  nature  of  the  disease,  as  in  the 
worst  forms  of  scarlet  and  typhus  fevers.  The  heart-clots  are  dark 
and  soft. 

Apart  from  inflammation  of  the  tonsils  and  cervical  glands,  the 
glandular  organs  are  not  changed  in  their  anatomical  character,  so 
far  as  ascertained,  with  the  exception  of  the  kidneys.  The  state 
of  the  kidneys,  and  character  of  the  urine,  will  be  described  here- 
after. 

Symptoms. — As  with  other  contagious  diseases,  the  symptoms 
vary  greatly  in  intensity  in  different  cases.  In  general,  in  the  com- 
mencement of  an  epidemic,  diphtheria  is  more  severe  and  fatal,  and 
its  symptoms  more  violent,  than  when  the  epidemic  influence  is 
abating.  The  prominent  symptoms  are,  however,  often  dispropor- 
tionate to  the  gravity  of  the  attack.  Striking  examples  of  this 
fact  might  be  given  from  cases  in  my  practice,  the  friends  not  sup- 
posing that  there  was  any  serious  ailment,  and  not  seeking  medical 
advice  till  the  fatal  termination  had  nearly  arrived.  Diphtheria 
corresponds,  in  this  respect,  with  all  those  affections  in  which  the 
blood  -is  profoundly  altered. 


^  SYMPTOMS.  233 

The  invasion  of  this  disease  may  be  gradual.  There  is  a  degree 
of  chilliness,  with  rigors,  often  slight,  succeeded  hy  more  or  less 
fever,  headache,  languor,  and  loss  of  appetite.  Still,  the  patient,  if 
old  enough,  continues  to  walk  about  as  if  affected  with  a  slight  and 
temporary  ailment.  The  sj^mptoms  are  like  those  of  a  cold,  for 
which,  indeed,  the  initial  stage  of  diphtheria  is  often  mistaken. 
"With  many,  one  of  the  first  symptoms  is  slight  tenderness  or  a 
sensation  of  fulness  in  the  fauces.  A  distinguished  clergjnnan  of 
the  Pacific  coast,  who  fell  a  victim  to  this  disease,  dreamed  a  few 
nights  before  he  complained  of  illness  that  his  throat  was  cut. 
Doubtless  the  diphtheritic  inflammation  had  already  commenced, 
so  that  what  seemed  a  forewarning  had  a  natural  explanation.  So 
insidious  was  the  commencement  in  this  case,  that  the  disease  had 
advanced  beyond  all  hope  of  relief  when  medical  advice  was  first 
sought. 

In  other  cases  the  invasion  is  more  abrupt  and  severe.  Great 
febrile  reaction,  headache,  pain  in  the  ear,  aching  of  the  limbs,  and 
loss  of  strength,  compel  the  patient  to  take  to  bed  from  the  first. 
Delirium  may  be  present,  but  it  is  unusual. 

The  symptoms  of  invasion  have  but  little  prognostic  value.  I 
have  met  cases  with  a  severe  commencement,  attended  by  delirium, 
which  terminated  in  complete  restoration  to  health  in  less  than  a 
week,  the  presence  of  the  membrane  upon  the  fauces,  and  the  occur- 
rence of  diphtheria  in  other  members  of  the  family,  rendering  the 
diagnosis  certain.  On  the  other  hand,  the  milder  commencement 
frequently  ushers  in  a  fatal  form  of  the  disease. 

The  slight  soreness  of  the  throat  or  sensation  of  fulness,  which 
accompanies  the  initial  stage  of  diphtheria,  does  not  ordinarily 
become  any  more  severe  during  the  course  of  the  attack,  and  it 
often  disappears  within  a  few  daj^s.  The  pain  on  swallowing,  and 
the  tenderness  when  pressure  is  made  upon  the  throat,  are  usually 
less  than  in  quinsy  or  simple  pharyngitis.  The  absence  or  mild- 
ness of  local  symptoms  is  the  main  reason  why  the  disease  is  so 
often  overlooked  in  its  first  stages.  I  have  known  more  than  once, 
in  consequence  of  the  slight  tenderness  in  the  throat,  the  large  ex- 
ternal swelling  to  be  mistaken  for  that  of  mumps,  till  an  incurable 
stage  of  the  affection  was  reached.  I  was  once  asked  to  see  a  little 
girl  about  ten  years  old,  on  account  of  this  external  swelling,  which 
was  limited  to  one  side,  and  the  character  of  which  the  parents  did 
not  understand.  A  physician  visiting  near  by  a  few  days  pre- 
viously, had  been  asked  to  see  this  patient,  and,  without  examining 
the  fauces,  attributed  the  swelling  to  inflammation  of  the  foot  of 


234  DIPHTHERIA. 

a  tooth,  and  had  not  thought  it  necessary  to  repeat  his  visit.  This 
child,  now  within  three  or  four  days  of  her  death,  was  walking 
about,  not  complaining  of  her  throat,  but  with  poor  appetite,  and 
with  the  pale,  cachectic  aspect  so  common  in  advanced  diphtheria, 
and  having  severe  inflammation  of  the  fauces,  with  a  thick  and  firm 
pseudo-membrane  extending  from  the  pharynx  forward  to  the  arch 
of  the  mouth.  The  mildness  of  subjective  symptoms  was  strikingly 
shown  in  another  case  which  came  to  my  notice.  A  little  girl  had 
been  ailing  a  few  days,  and  had  the  external  cervical  swelling,  but 
continued  about  the  house  and  amused  herself  with  playthings, 
even  jumping  the  rope  a  few  times  on  the  day  of  her  death.  Finally, 
she  sank  rapidly  of  exhaustion,  dying  before  a  physician  could 
arrive.  These  sudden  and  unexpected  deaths  in  diphtheria  are 
due  to  the  profoundly  altered  state  of  the  blood.  If  the  inflamma- 
tion invade  the  larynx,  then  the  symptoms  are  immediately  con- 
spicuous and  alarming. 

The  tongue  in  diphtheria  is  covered  with  a  moist  fur ;  sometimes 
more  or  less  of  the  exudation  appears  upon  it;  the  apj)etite  is  poor; 
bowels  regular.  The  pulse  in  different  cases  varies  greatly  in  vol- 
ume and  frequency.  It  is  often  full  and  strong  in  the  first  days  of 
the  disease,  but  in  the  latter  part,  when  death  from  asthenia  ap- 
proaches, it  is  feeble  and  frequent.  At  first  there  are  no  marked 
symptoms  referable  to  the  respiratory  apparatus.  There  is  only  that 
degree  of  acceleration  of  respiration  which  corresponds  with  the 
amount  of  fever.  In  many  cases,  favorable  as  well  as  unfavorable, 
there  is  no  cough  and  no  embarrassment  of  respiration  throughout 
the  entire  sickness,  though  the  inflammation  of  the  faucial  surface 
may  be  general  and  severe,  and  the  constitutional  disturbance  very 
decided.  But  ordinarily,  in  the  course  of  a  few  days  from  the 
inception  of  the  disease,  the  swelling  of  the  nasal  mucous  mem- 
brane, and  the  occurrence  of  exudation  upon  it,  produce  snuflHing 
respiration.  The  occurrence  of  the  phlegmasia  upon  the  laryngo- 
tracheal surface  is  indicated  by  hoarseness  of  the  voice,  and  an  occa- 
sional dry  cough,  and  as  the  inflammation  extends  and  the  pseudo- 
membrane  forms,  the  cough  becomes  more  frequent,  and  harsh  or 
raucous,  as  in  true  croup.  Indeed,  the  condition  of  the  patient, 
as  regards  the  larynx  and  trachea  in  diphtheria,  when  they  are  the 
seat  of  fibrinous  exudation,  resembles  that  in  true  croup.  As  the 
inflammation  in  the  larynx  and  trachea,  when  accompanied  by 
fibrinous  exudation,  is  rarely  amenable  to  treatment,  the  symptoms 
of  obstructed  respiration  become  more  continuous  and  severe  as  the 
disease  advances,  till  finally  the  dyspnoea  is  extreme;  the  inspira- 


4 


SYMPTOMS.  235 

tion  is  protracted  and  whistling,  and  accompanied  by  great  depres- 
sion of  the  ribs;  the  countenance  is  anxious  and  pallid;  the  prola- 
bia  and  fingers  livid,  and  the  little  patient  in  vain  seeks  for  relief 
by  change  of  position.  Occasionally,  by  great  effort  on  the  part 
of  the  child,  or  by  fortunate  treatment,  a  portion  of  the  pseudo- 
membrane  is  expectorated,  and  for  some  hours  there  is  apparently 
marked  improvement,  but  it  is  only  in  exceptional  cases  that  the 
membranous  formation  is  not  speedily  and  fully  reproduced.  As 
death  draws  near,  the  cough  diminishes  both  in  frequency  and  force. 

In  cases  of  a  severe  type  the  breath  is  ordinarily  offensive,  having 
a  gangrenous  odor.  There  is  in  such  patients  intense  pharyngitis, 
with  a  pseudo-membrane  which,  from  its  low  vitality,  rapidly  un- 
dergoes decay,  and  also  great  external  swelling  from  the  adenitis 
and  cellulitis. 

An  efflorescence  is  sometimes  observed  upon  the  surface  during 
the  period  when  the  temperature  of  the  skin  is  exalted.  This  rash 
does  not  difier  from  ordinar}^  erythema  so  common  in  the  febrile 
and  inflammatory  aflfections  of  infancy  and  early  childhood.  It  is 
not  attended  by  the  minute  papulte  which  produce  roughness  of 
the  surface  in  scarlet  fever.  It  is  the  erythema  fugax  of  dermatolo- 
gists suddenly  appearing,  and  after  some  hours  as  suddenly  disap- 
pearing. In  many  patients  it  is  absent,  and  it  is  seldom  if  ever 
observed,  except  in  the  first  days,  when  there  is  an  active  circula- 
tion. 

The  symptoms  pertaining  to  the  nervous  system,  which  are  ordi- 
narily most  prominent,  I  have  already  described.  I  have  described 
the  cephalalgia  and  muscular  pains,  which  are  present  in  the  initial 
period,  but  they  soon  abate.  Convulsions  may  occur  in  young 
children,  but  not  oftener  than  in  other  diseases  attended  by  febrile 
reaction. 

The  heat  of  surface  is  in  most  cases  less  than  in  scarlet  fever ;  it 
abates  in  a  few  days,  and  in  advanced  stages  of  the  disease  the 
temperature  is  natural  or  less  than  natural.  The  abdominal  organs 
are  seldom  much  affected  in  diphtheria,  so  far  as  ascertained,  with 
the  exception  of  the  kidneys.  There  have  not  been  many  chemical 
examinations  of  the  urine  in  this  disease,  but  in  a  few  which  have 
been  made  (Sanderson,  British  and  Foreign  Medico-Chir.  Rev.,  Jan- 
uary, 1860),  the  quantity  of  urea  excreted  daily  was  found  to  be 
considerably  more  than  when  convalescence  had  commenced.  The 
most  interesting  and  important  change,  however,  in  the  constitution 
of  the  urine,  is  the  occurrence  of  albumen  in  it.  This  element  was 
first  discovered  by  Mr.  Wade,  of  Birmingham,  in  1857,  and  since 


236  DIPHTHEEIA. 

then  various  observations  in  different  epidemics  and  localities 
establish  the  fact  that  albuminuria  occurs  in  the  majority  of  cases 
of  severe  diphtheria,  and  in  many  of  a  mild  form.  It  often  occurs 
at  an  early  period,  but  in  other  patients  it  does  not  appear  till  the 
close  of  the  first  week,  or  commencement  of  the  second.  It  con- 
tinues three  or  four  days  to  as  many  weeks,  when  in  favorable  cases 
it  gradually  becomes  less  and  soon  disappears.  While  albuminuria 
is  more  common  in  diphtheria  than  in  scarlet  fever,  the  quantity 
of  albumen  in  the  urine  is  ordinarily  less  than  in  that  disease.  The 
albuminuria  of  diphtheria  is  further  distinguished  from  that  of 
scarlet  fever  in  the  fact  already  stated,  that  it  ordinarily  occurs  in 
the  midst  of  the  disease,  and  is  attended  by  slight  anasarca,  often 
by  none,  whereas  in  scarlet  fever  it  occurs  after  the  subsidence  of 
the  fever,  is  attended  by  greater  anasarca,  and  even  serous  eft'usion 
in  the  cavities.  If  we  examine  the  albuminous  urine  of  diphtheria 
with  the  microscope,  we  find  in  it  fibrinous  casts  and  altered  renal 
epithelial  cells.  These  cells  are  opaque  or  granular,  mainly  from 
the  deposit  of  fatty  particles  in  their  interior.  But  this  appearance 
of  the  cells  is  not  peculiar  to  diphtheritic  albuminuria. 

Albuminuria  in  diphtheritic  patients  is,  in  the  present  state  of 
our  knowledge,  rather  a  matter  of  scientific  interest  than  of  prac- 
tical importance.  It  does  not  seem  to  be  an  unfavorable  prognostic 
sign,  and  in  most  cases  it  requires  no  special  treatment.  Occasion- 
ally there  is  a  considerable  amount  of  albumen  in  the  urine  in 
cases  which  are  not  severe,  and  the  quantity  in  the  same  patient 
may  vary  from  day  to  day.  In  some  grave  cases  of  diphtheria  the 
urine  is  scanty,  and  there  is  then  danger  of  ursemic  poisoning.  If 
there  is  great  and  continued  deficiency,  death  may  occur  from  this 
cause  in  convulsions  and  coma. 

The  course  of  diphtheria,  like  the  intensity  of  its  symptoms 
varies  greatly  in  dift'erent  cases,  whether  the  result  be  favorable  or 
unfavorable.  Complete  recovery  may  occur  within  a  few  days,  less 
indeed  than  a  week,  but  in  other  and  perhaps  a  majority  of  favora- 
ble cases  weeks  elapse  before  the  health  is  completely  restored. 
When  the  disease  is  so  protracted,  the  pseudo-membrane  is  detached 
slowly,  or  being  detached,  it  is  reproduced  again  and  again.  In 
these  lingering  cases,  the  countenance  bears  the  appearance  of 
marked  cachexia,  the  appetite  remains  poor  or  capricious,  the 
features  are  pallid,  the  body  more  or  less  wasted,  and  the  strength 
reduced.  Convalescence  of  such  patients  is  slow  and  jDrotracted, 
even  after  the  inflammation  has  entirely  disappeared. 

The  course  of  diphtheria  lacks  uniformity  in  fatal  not  less  than  in 


i 


NATURE.  237 

favorable  cases.  I  have  known  death  to  occur  in  a  robust  child  of 
two  years  and  three  months  on  the  fourth  day,  without  cough,  and 
entirely  from  the  malignant  nature  of  the  affection.  The  strength 
was  overpowered,  and  life  so  suddenly  extinguished  by  the  intensity 
of  the  diphtheritic  virus.  In  this  case  there  was  great  external 
swelling  and  intense  pharyngitis.  In  other  cases,  as  has  been  pre- 
viously stated,  death  occurs  from  diphtheritic  croup.  In  other,  and 
a  large  proportion  of  fatal  cases,  the  disease  is  more  protracted. 
Without  embarrassment  of  respiration,  and  often  apparently  with 
but  moderate  inflammation,  the  patient  gradually  loses  flesh  and 
strength.  The  face  presents  a  pallid  and  cachectic  aspect,  and 
sometimes  there  is  a  general  flabby  or  cedematous  appearance ;  the 
appetite  is  poor,  and  is  improved  but  little  by  tonics ;  the  pulse 
is  accelerated,  and  is  day  by  day  more  feeble,  till,  finally,  death 
occurs  from  asthenia.  In  these  lingering  and  dubious  cases,  all 
hope  of  recovery  is  sometimes  dissipated  by  the  occurrence  of 
abundant  hemorrhage  from  the  throat,  in  consequence  of  detach- 
ment of  the  pseudo-membrane  and  consequent  rupture  of  the 
capillaries,  or  possibly  sometimes  from  ulcers  in  the  throat.  I  was 
once  treating  a  little  girl  about  nine  years  old  with  diphtheria 
accompanied  by  pretty  severe  pharyngitis,  and  she  had  entered 
the  third  week,  with  prospect  of  a  favorable  issue  of  the  disease, 
when  she  was  suddenly  seized  with  profuse  hemorrhage  from  the 
fauces,  which  was  repeated,  and  death  occurred  in  forty-eight  hours. 
So  unexpected  a  result  was  apparently  due  to  separation  of  the 
false  membrane. 

Nature. — Though  the  inflammatory  lesions  in  diphtheria  are 
so  severe  and  dangerous,  they  sustain  a  secondary  relation  to  the 
disease  itself.  Diphtheria  must  be  placed  in  the  same  category 
with  smallpox,  scarlet  fever,  measles,  and  other  infectious  diseases. 
Like  them,  it  is  due  to  a  specific  virus.  These  diseases,  though 
dissimilar  in  nature  and  appearance,  are  controlled  by  the  same 
general  laws,  so  that  they  are  very  similar  as  regards  the  mode  of 
their  occurrence.  That  there  is  a  miasm  generated  in  the  persons 
of  those  afl'ected,  and  which  propagates  the  disease,  is  shown  by 
numerous  observations.  The  infectious  nature  of  diphtheria  is, 
however,  doubted  by  some,  though  admitted  by  most  pathologists. 
Facts  such  as  those  which  prove  the  communicability  of  scarlet 
fever  and  measles,  have  been  repeatedly  observed  in  reference  to 
diphtheria.  Diphtheria,  if  it  enters  a  family  of  children  during 
its  epidemic  prevalence,  usually  attacks  more  than  one.  It  attacks 
those  who  remain  in  the  same  room  with  a  diphtheritic  patient, 


238  DIPHTHERIA. 

wliile  those  staying  in  separate  apartments  escape.  In  the  late 
epidemic  of  diphtheria  in  this  city,  I  was  asked  to  see  a  boy  about 
ten  years  old  with  diphtheria.  The  father  had  left  home  a  few 
days  previously,  and  escaped  the  disease.  A  servant  girl,  who  was 
much  frightened  and  remained  in  a  distant  jiart  of  the  house,  also 
escaped.  Three  sisters,  who  were  daily  exposed  to  the  boy,  took 
the  disease  within  the  ensuing  week,  in  a  mild  form.  All  had  the 
pseudo-membrane,  though  of  limited  extent.  Such  facts,  and 
there  are  many  of  a  similar  nature  contained  in  the  literature  of 
diphtheria,  establish  the  doctrine  of  the  communicability  of  this 
disease  as  securely  as  almost  any  doctrine  in  pathology. 

It  is  not  known  certainly  whether  diphtheria  is  inoeulable,  but 
it  is  believed  by  many  that  the  saliva  and  pseudo-membrane  of  a 
diphtheritic  patient,  applied  to  the  abraded  cutaneous  surface  or  to 
the  mucous  membrane,  may  communicate  the  disease.  The  illus- 
trious Yalleix,  whose  writings  hold  so  conspicuous  a  place  in  the 
literature  of  children's  diseases,  was  attending  a  child  with  diph- 
theria. One  day,  on  examining  the  throat  of  his  patient,  he  re- 
ceived in  his  mouth  a  little  of  the  saliva,  ejected  in  the  effort  of 
coughing.  The  next  day  a  small  concretion  appeared  on  one  tonsil. 
The  inflammation  and  the  pseudo-membrane  extended,  and  in 
forty-eight  hours  Valleix  died,  though  his  patient  recovered.  This 
case  and  others  similar  to  it,  which  have  been  published,  do  not 
prove  the  inoculability  of  diphtheria,  for  the  same  result  might 
have  occurred  in  the  ordinary  mode  in  which  contagious  diseases 
are  transmitted,  namely,  by  infection.  But  as  all  who  have  seen 
much  of  diphtheria,  from  the  time  of  Bretonneau,  have  now  and 
then  observed  cases  analogous  to  that  of  Yalleix,  it  is  the  part  of 
prudence,  till  the  question  of  inoculability  is  settled,  to  avoid  all 
needless  exposure.  Bretonneau  believed  not  only  in  the  inocula- 
bility, but  that  this  was  the  only  way  in  which  diphtheria  is  com- 
municated. 

Diphtheria  also,  like  typhus  fever,  often  occurs  without  exposure. 
Whenever  it  visits  a  region,  it  commences  in  localities  remote  from 
each  other,  some  of  which  are  so  secluded  as  to  negative  the  idea 
of  importation.  For  example,  in  this  country  as  well  as  in  Great 
Britain,  during  the  recent  epidemic,  it  prevailed  in  remote  farming 
sections  as  early  and  sometimes  earlier  than  in  the  commercial 
centres.  Children  who  had  lived  for  months  secluded  in  farm- 
houses were  sometimes  the  first  to  be  affected. 

Infectious  diseases  have  a  period  of  incubation.  Observations 
show  that  this  is  short  in  diphtheria,  though,  as  in  scarlet  fever,  it 


SEQUEL.E.  239 

seems  to  vary  in  difFerent  cases.     Tliis  period  is  usually  from  two 
to  seven  days. 

Diplitheria,  whatever  the  local  manifestations,  is  always  essen- 
tially the  same  disease.  A  mild  may  communicate  a  severe  form, 
and  vice  versa,  and  cases,  which  at  first  view  might  appear  to  he 
different  on  account  of  difference  in  the  seat  of  the  phlegmasia,  are 
shown  to  be  identical  in  nature  by  occurring  together,  and  in  conse- 
quence of  the  same  exposure. 

Allusions  have  already  been  made  to  the  epidemic  character  of 
diphtheria.  Sporadic  cases  occasionally  occur.  The  epidemic  form 
is  more  severe  and  fatal  than  the  sporadic.  The  history  of  the 
various  epidemics  shows  the  universality  of  the  specific  virus,  for 
diphtheria  has  prevailed  in  all  seasons,  in  all  or  nearly  all  climates, 
in  the  rural  districts,  remote  and  sparsely  settled,  as  well  as  in 
cities,  and  in  mountainous  regions  as  well  as  in  valleys.  It  is, 
however,  most  prevalent  and  fatal  where  anti-hygienic  conditions 
prevail,  as  in  the  tenement-houses  of  the  city,  and  especially  in  such 
apartments  as  are  dark  and  damp,  but  which  necessity  compels  the 
poor  to  occupy.  A  large  proportion  of  the  severe  cases  seen  by 
myself,  during  the  recent  epidemic  in  'New  York,  occurred  in  the 
upper  part  of  the  city,  along  the  old  watercourses,  where,  in  conse- 
quence of  grading  of  the  streets,  there  was  more  or  less  stagnant 
water,  which  was  impregnated  with  decaying  animal  and  vegetable 
matter.  In  these  localities,  even  where  the  population  was  sparse, 
some  of  the  first  as  well  as  last  cases  of  the  epidemic  occurred,  and 
a  large  portion  of  those  aflected  died. 

Diphtheria  occurs  at  any  age.  I  have  known  the  infant  of  three 
months  die  of  it,  and  many  adults  fall  victims  when  it  prevails  as 
an  epidemic.  Much  the  largest  number  of  cases,  however,  occur 
between  the  ages  of  two  years  and  eight  or  ten.  The  occurrence 
of  this  disease  at  so  early  an  age  as  three  months,  and,  on  the  other 
hand,  in  adult  life,  affords  one  point  of  contrast  between  diphtheria 
and  scarlet  fever,  as  well  as  true  croup,  both  which  rarely  occur  at 
so  early  and  so  advanced  an  age. 

Sequels. — Those  who  recover  from  a  severe  attack  of  diphtheria, 
remain  often  for  weeks  with  a  pale  and  cachectic  appearance.  The 
blood  is  evidently  profoundly  altered,  so  that  there  is  a  deficiency 
of  red  corpuscles  or  a  state  of  spansemia,  which  slowly  disappears. 
This  is  a  common  result  of  protracted  constitutional  diseases,  but 
it  is  more  noticeable  after  this  than  most  kindred  affections.  The 
excretion  of  albumen  from  the  kidneys  no  doubt  increases  mate- 
rially the  impoverishment  of  the  blood. 


2-iO  DIPHTHERIA. 

There  is  another  sequel,  which  possesses  great  interest,  as  it  is 
common  in  diphtheria,  and  as  its  etiology  is  not  fully  understood. 
This  sequel  is  paralysis.  Paralysis  does  not  occur  till  after  the 
abatement  of  the  inflammatory  symptoms.  The  patient  seems  fully 
convalescent.  The  fever  has  ceased ;  the  appetite  is  returning ;  the 
ansemia  is  becoming  less,  and  there  is  prospect  of  speedy  restoration 
to  health,  when  this  nervous  affection  is  developed.  The  interval 
between  the  subsidence  of  the  inflammation  and  the  commencement 
of  the  paralysis  is  usually  two  or  three  weeks.  The  muscles  most 
frequently  affected  are  those  of  the  pharynx,  so  that  deglutition  is 
rendered  difficult,  to  such  a  degree  often,  that  nutrition  is  seriously 
interfered  with.  The  aliment  taken  passes  back  through  the  nos- 
trils, or  is  not  swallowed  till  after  several  successive  efforts.  In 
the  attempt  to  swallow,  a  portion  of  the  food  sometimes  enters  the 
larynx,  so  as  to  produce  violent  coughing.  As  we  observe  the  dys- 
phagia, it  seems  as  if  there  must  be  pharyngitis,  which  renders 
deglutition  difficult,  but  on  inspecting  the  fauces  we  find  no  evi- 
dences of  inflammation.  The  mucous  membrane  has  recovered  its 
normal  appearance,  and  the  nerves  only  are  affected.  The  velum 
palati  hangs  flaccid  and  motionless,  like  a  curtain.  In  some  there 
is  only  pharyngeal  paralysis,  but  in  many  this  nervous  affection 
occurs  in  other  parts.  Whenever  it  occurs  elsewhere,  the  pharj^ngeal 
muscles  are  nearly  always  involved  at  the  same  time.  Diphtheritic 
paralysis  may  affect  the  motor  muscles  of  the  eye,  causing  strabis- 
mus; the  muscles  of  one  side,  causing  hemiplegia;  of  the  legs,  caus- 
ing paraplegia ;  or  of  an  arm  on  one  side  and  leg  on  the  opposite. 
It  does  not  commence  simultaneously  in  the  various  muscles  which 
are  affected,  but  in  succession,  those  first  affected  being  for  the  most 
part  the  muscles  of  the  pharynx.  In  some  the  muscles  of  the  blad- 
der have  been  paralyzed,  leading  to  retention  of  urine  or  difficulty 
in  passing  it.  Paralysis  in  the  limbs  is  frequently  preceded  by 
tingling  or  a  sensation  of  formication.  There  is  often  not  a  total 
loss  of  sensation  or  of  motion  in  the  paralyzed  part,  but  there  is 
numbness  with  great  difficulty  rather  than  impossibility  of  motion. 
A  few  cases  have  been  reported  in  which  the  paralysis  was  almost 
general,  and  some  believe  that  they  have  met  cases  in  which  the 
heart  was  paralyzed,  death  occurring  suddenly  and  unexpectedly. 
Dr.  J.  B.  Reynolds  relates  a  case  in  the  Nexo  York  Journ.  of  Med.^ 
May,  1860,  in  which  there  was  not  only  strabismus,  partial  paralysis 
of  the  limbs,  and  paralysis  of  the  muscles  of  the  pharynx,  so  that 
food  was  regurgitated,  but  the  head  dropped  forward  so  that  the 
chin  rested  on  the  sternum. 


PROGNOSIS.  241 

A  majority  of  those  affected  with  paralysis  recover,  although  few 
regain  the  complete  use  of  their  muscles  in  less  than  one  month, 
and  many  do  not  till  between  two  and  four  months. 

Defect  of  vision  is  an  occasional  result  of  diphtheria;  some  have 
presbyopia ;  others  myopia ;  some  see  douhle ;  some  are  amaurotic ; 
while  in  others  one  pupil  is  more  dilated  than  the  other,  or  both 
pupils  are  dilated,  and  feebly  sensitive  to  light.  This  impairment 
or  perversion  of  vision  gradually  disappears  as  the  vigor  of  system 
returns. 

Prognosis. — The  prognosis  in  diphtheria  is  more  favorable  when 
it  occurs  sporadically,  or  at  the  close  of  an  epidemic,  than  when  the 
epidemic  influence  is  prevailing.  Though  a  constitutional  disease, 
its  gravity  is  in  a  majority  of  cases  proportionate  to  the  local  symp- 
toms. Therefore,  intense  pharyngitis,  an  extensive  pseudo-mem- 
brane, and  great  cervical  cellulitis  and  adenitis,  indicate  a  form  of 
the  disease  which  usually  proves  fatal  in  the  robust  as  well  as 
weakly.  When  the  inflammation  extends  to  the  larynx,  and  the 
phenomena  of  croup  arise,  there  is  slight  prospect  of  recovery. 
Pseudo-membranous  laryngitis  is  then  present  in  addition  to  the 
depressing  influence  of  the  diphtheritic  virus.  The  local  disease, 
apart  from  the  constitutional,  we  know  to  be  ordinarily  fatal. 
Much  more  unfavorable,  then,  is  the  prognosis  if  the  two  are  com- 
bined. When  the  croupy  cough,  voice,  and  respiration  are  observed, 
he  will  seldom  err  who  predicts  a  fatal  result  within  a  week,  and 
often  death  follows  in  two  or  three  days. 

Great  acceleration  of  the  pulse  continuing  after  the  first  week, 
a  countenance  pallid,  with  softness  or  flabbiness  of  the  tissues,  the 
occurrence  of  hemorrhage  from  the  fauces  or  other  parts,  are  prog- 
nostic of  an  unfavorable  ending.  The  secondary  form  of  diphtheria 
is  more  apt  to  prove  fatal  than  the  primary,  in  consequence  of  the 
depressing  effect  of  the  antecedent  disease. 

From  what  has  already  been  stated,  it  is  obviously  injudicious 
to  predict  a  favorable  or  an  unfavorable  termination  from  the  cha- 
racter of  the  initial  symptoms,  since  an  obstinate  and  fatal  case 
often  commences  mildly,  and  cases  easily  managed  may  commence 
with  violent  symptoms.  But  if  the  inflammations,  mucous  and 
glandular,  remain  of  a  mild  grade,  if  the  pulse  is  not  greatly  accele- 
rated, if  the  constitution  is  good,  and  there  are  no  laryngeal  sym[>- 
toms,  a  good  result  is  highly  probable. 

In  many  cases,  after  the  active  symptoms  have  somewhat  abated, 
the  result  for  days  or  even  weeks  is  uncertain  on  account  of  the 
ana3mia.     A  majority,  however,  who  have  passed  through  diph- 
16 


242  DIPHTHERIA. 

theria,  recover,  even  if  there  is  great  impoverishment  of  the  hlood, 
provided  that  there  are  no  serious  local  symi^toms.  Diphtheritic 
paralysis,  which  is  so  alarming  to  friends,  may  continue  several 
months,  but  it  is  very  seldom  permanent,  perhaps  never.  Only  in 
exceptional  instances  do  patients  afl'ected  with  it  die.  This  result 
is  probably  due  in  general  to  imperfect  nutrition,  resulting  directly 
from  the  diphtheria,  or  from  the  dysphagia,  which  is  present  in 
consequence  of  the  paralysis. 

Diagnosis. — The  liability  of  mistaking  simple  pharyngitis,  when 
attended  by  the  growth  of  conferva,  for  diphtheria,  has  been  already 
sufficiently  pointed  out.  By  the  microscope  the  diagnosis  in  such 
cases  is  rendered  easy.  The  greater  amount  of  external  swelling  in 
pseudo-membranous  pharyngitis  is  also  a  means  of  distinguishing 
this  disease  from  the  simple  form.  There  is,  in  some  cases,  a  close 
resemblance  of  diphtheria  to  scarlet  fever,  especially  as  regards 
the  condition  of  the  system  generally,  the  pharyngitis,  and  the 
external  glandular  swelling.  The  rash  upon  the  skin,  and  the  ab- 
sence of  a  pseudo-membrane  upon  the  fauces,  in  scarlet  fever,  are 
usually  sufficient  to  establish  the  diagnosis.  In  almost  all  cases  of 
diphtheria,  this  pseudo-membrane  can  be  seen  on  inspecting  the 
fauces.  The  cases  in  which  it  is  not  visible,  during  the  active 
period  of  the  disease,  are  so  few  that  no  account  need  be  taken  of 
them.  The  superficial  gangrenous  state  of  the  throat,  occasionally 
present  in  scarlet  fever,  can  be  distinguished  by  careful  examination 
from  the  pseudo-membranous  pharyngitis  of  diphtheria.  Occasion- 
ally anginose  scarlet  fever  is  attended  by  a  fibrinous  exudation, 
especially  upon  the  tonsils,  but  the  quantity  is  small,  unless,  in- 
deed, there  is  at  the  same  time  diphtheria.  Practically,  however, 
it  matters  little  whether  we  make  a  differential  diagnosis  of  scarlet 
fever  and  diphtheria,  as  the  two  require  very  similar  therapeutic 
measures. 

Diphtheria,  with  the  pseudo-membranous  laryngitis,  and  true 
croup,  present  great  similarity  as  regards  symptoms.  One  has  often 
been  mistaken  for  the  other,  to  the  detriment  of  the  patient,  for 
these  two  diseases  require  different  treatment.  With  proper  care, 
however,  in  examination,  with  a  knowledge  of  the  history  of  the 
case,  the  character  of  the  affection  can  generally  be  ascertained. 
The  inflammation  of  croup  generally  begins  in  the  larynx,  and  the 
pharynx,  though  inflamed,  is  inflamed  secondarily;  whereas  the 
inflammation  of  diphtheria  begins  in  the  pharynx,  the  laryngitis 
occurring  some  days  later.  Therefore,  in  diphtheria  there  is  usually 
the  fever,  with  tenderness  and  tumefaction  of  the  faucial  surface, 


TREATMENT.  243 

and  fibrinous  exudation,  before  the  cough  or  other  symptoms  of 
laryngitis  occur.  In  croup  the  characteristic  voice  and  cough  are 
present  from  the  first,  and  if  we  inspect  the  fauces  in  the  com- 
mencement of  the  disease,  we  find  only  a  degree  of  redness,  and 
though  at  a  later  period  points  or  patches  of  pseudo-membrane 
may  be  observed,  the  inflammation  of  the  pharynx  remains  less 
intense  throughout  the  disease  than  that  of  the  larynx,  as  shown 
by  the  symptoms.  The  pseudo-membrane  of  diphtheria  penetrates 
the  mucous  coat,  and  is  fibrinous;  while  that  of  croup  lies  on  the 
surface,  and  consists  chiefly,  if  not  entirely,  of  degenerated  epi- 
thelial cells,  with  mucus  and  pus.  By  attending  to  these  par- 
ticulars, a  correct  diagnosis  of  croup  and  diphtheria  can  ordinarily 
be  made. 

Treatment. — It  has  been  proposed,  in  the  treatment  of  this  and 
other  infectious  diseases,  to  give  medicines  to  prevent  the  supposed 
fermentative  processes  going  on  in  the  economy,  and  by  this  means 
to  ameliorate,  if  not  entirely  control,  the  morbid  action.  Prof. 
Polli,  of  Milan,  has  recommended  for  this  purpose  the  use  of  the 
sulphites,  in  the  belief  that  the  sulphurous  acid  set  free  in  the  sys- 
tem by  their  decomposition,  prevents,  or  tends  to  prevent,  catalysis. 
Experiments  have  shown  that  this  agent  does  check  fermentation 
without  the  system,  and  the  theory  of  Polli  possesses  a  degree  of 
plausibility.  But  in  such  matters  the  only  reliable  guide  is  expe- 
rience. The  doctrine  of  catalysis  in  disease  is  indeed  merely,  as 
yet,  an  hypothesis,  having  the  appearance  of  correctness.  If  expe- 
rience show  that  the  sulphites  are  beneficial  in  the  treatment  of  the 
so-called  zymotic  affections,  we  are  then,  and  only  then,  justified  in 
employing  them.  In  our  present  imperfect  knowledge  of  pathology 
and  of  the  action  of  medicines,  theorizing  should  succeed  observa- 
tion. It  is  difiicult  to  determine  the  exact  value  of  any  medicine 
in  the  treatment  of  zymotic  diseases,  since  so  many  cases  terminate 
favorably  without  medicines,  but  some  of  the  physicians  of  this 
city  who  have  used  the  sulphites  speak  favorably  of  their  effect. 
My  own  experience  with  them  has  been  limited.  I  have  seen  im- 
provement in  severe  scarlet  fever  when  these  agents  were  employed 
but  remained  in  doubt  whether  the  same  result  would  not  have  fol- 
lowed with  the  use  of  other  measures.  The  most  eligible  of  the 
sulphites  is  the  bisulphite  of  soda,  since  this  gives  a  large  amount 
of  sulphurous  acid,  has  no  purgative  efi'ect,  like  some  of  the  sul- 
phites, or  other  injurious  action,  and,  from  its  name,  insures  against 
any  mistake  on  the  part  of  the  druggist.  The  word  sul|ihite  has 
been  mistaken  in  a  prescription  for  sulphate,  the  error  not  being 


244  DIPHTHERIA. 

detected  till  the  child  was  weakened  by  purgation.  Bisulphite  of 
soda  is  readily  soluble  in  water  as  well  as  alcohol,  and  to  a  child  of 
three  to  five  years  one  to  two  drachms  may  be  given  in  twenty- 
four  hours,  in  doses  of  five  to  ten  grains. 

R.  Sodse  bisulphit.  gj-ij  ; 
Tinct.  aurant.  ^^ij  ; 
Aquse  5x.     Misce. 
Dose,  one  teaspoonful  every  two  hours.     Sometimes  in  place  of  water  a  bitter 
infusion  like  that  of  quassia  has  been  employed. 

Death  in  diphtheria,  as  we  have  seen,  ordinarily  occurs  from  ex- 
haustion or  from  obstructed  respiration.  Knowledge  of  this  fact 
aids  in  the  choice  of  therapeutic  measures.  Diphtheria  is  decidedly 
an  asthenic  disease;  therefore  sustaining  treatment  is  required. 
From  the  first,  although  the  pulse  is  strong,  the  surface  hot,  and 
features  flushed,  all  measures  of  a^ depressing  nature  must  be  care- 
fully avoided.  Great  febrile  excitement,  in  connection  with  robust- 
ness of  system,  may  incline  us  to  the  use  of  cardiac  sedatives,  but 
they  should  not  be  administered,  or  if  administered,  only  the  mild- 
est should  be  given  and  with  caution,  since  diphtheria,  if  it  con- 
tinue a  few  days,  is  attended  by  evident  symptoms  of  prostration, 
whatever  the  mode  of  commencement.  Nutritious  food,  like  the 
animal  broths,  should  be  given  often  and  in  a  concentrated  form, 
on  account  of  the  diificulty  of  swallowing,  and  recourse  should  be 
had  to  alcoholic  stimulants,  as  wine-whey  or  milk-punch,  as  soon 
as  there  are  any  indications  of  feebleness.  An  extensive  pseudo- 
membrane  and  great  glandular  swelling  show  a  form  of  the  disease 
which  requires  immediate  and  active  sustaining  measures.  The 
apartment  occupied  by  the  patient  should  be  kept  clean  and  dry,  as 
indeed  it  should  be  in  the  treatment  of  any  infectious  disease.  A 
change  of  apartments  during  the  day  is  also  advisable,  particularly 
in  those  cases  in  which  there  is  a  gangrenous  odor. 

As  the  sulphites  have  not  been  employed  sufficiently  long  to  de- 
termine their  value,  or  whether,  indeed,  they  have  any  eftect  in 
controlling  diphtheria,  it  does  not  seem  judicious  until  they  are 
more  fully  tested,  and  are  found  to  accomplish  what  is  claimed  for 
them  on  theoretical  grounds,  to  discard,  in  cases  that  are  at  all 
critical,  those  remedies  which  appear  to  be  indicated  from  the 
nature  of  the  disease,  and  which  have  met  general  approval  of  the 
profession.  These  remedies  are  the  tonics,  vegetable  and  ferrugi- 
nous. 

A  large  number  of  these  medicinal  agents  might  be  mentioned, 
all  of  which  would  be  likely  to  result  in  more  or  less  benefit,  but 


TREATMENT.  245 

I  will  only  mention  such  combinations  as  are  well  adapted  to  meet 
the  various  indications. 

Chlorate  of  potash  or  soda,  and  tincture  of  the  chloride  of  iron, 
are  the  two  remedies  which  have  been  most  employed  in  this  country 
and  in  Europe,  on  account  of  their  supposed  local  effect  on  the 
inflamed  surface,  and  the  latter  on  account  of  its  eminently  tonic 
properties.  Prescribed  in  combination,  these  medicines  are  not 
unpleasant  to  the  taste,  and  I  consider  this  mixture  one  of  the  very 
best  for  ordinary  cases  of  diphtheria: — 

R.  Tinct.  ferri  chloridi  3j ; 
Potas.  chlorat.  5j  ; 
Syr.  simplic.  3ij.     Misce. 
Dose,  one  teaspoonful  every  two  or  three  hours  to  a  child  of  three  years. 

I  have  usually  given  directions  to  allow  no  drinks  to  the  patient 
for  a  few  minutes  after  each  dose,  in  order  that  the  full  local  effect 
may  be  obtained.  The  tincture  of  the  chloride  of  iron  alone,  the 
wine  of  iron,  or  any  of  the  other  ferruginous  preparations,  may  be 
advantageously  administered,  especially  in  ansemic  cases,  in  place 
of  the  mixture  mentioned  above.  In  those  of  full  habit  and  florid 
complexion,  iron  is  not  so  imperatively  required.  In  such  cases 
the  elixir  of  Calisaya  bark,  in  doses  of  one  teaspoonful  to  a  table- 
spoonful,  according  to  the  age,  is  a  useful  and  not  unpleasant 
remedy.  The  fluid  extract  of  cinchona  or  col  umbo  also  meets  the 
indication. 

There  is  difference  of  opinion  as  regards  the  value  of  local  treat- 
ment in  diphtheria.  Some  hold  that  as  it  is  a  constitutional 
malady,  and  that  as  death  in  it  is  ordinarily  due  either  to  exhaus- 
tion or  to  inflammation  of  the  larynx,  which  we  cannot  subject  to 
any  reliable  local  treatment,  therefore  topical  measures  directed  to 
the  throat,  which  worry  and  fatigue  the  child,  are  not  advisable. 
But,  as  Trousseau  has  remarked,  the  gravity  of  diphtheria  is  usu- 
ally proportionate  to  the  amount  of  local  disease,  and  if,  therefore, 
we  can  moderate  the  intensity  of  the  inflammation,  we  increase  the 
chances  of  a  favorable  issue.  The  local  disease  reacts  on  and  intensi- 
fies the  constitutional,  increasing  the  febrile  movement,  and  ex- 
hausting the  strength  of  the  patient.  Again,  it  is  probable,  though 
this  opinion  is  not  held  by  some,  that  the  laryngitis  of  diphtheria 
often  results  from  extension  downward  of  thefaucial  inflammation. 

For  these  reasons,  direct  treatment  calculated  to  diminish  the 
intensity  of  the  faucial  inflammation  is  proper,  and  yet  those  severe 
caustic  applications,  formerly  much  employed,  and  still  used  by 
some  practitioners,  by  causing  great  pain  and  restlessness,  weaken 


246  DIPHTHERIA. 

the  child,  and  do  more  harm  than  good.  Great  gentleness  on  the 
part  of  the.  physician,  in  making  applications  to  the  throat,  cannot 
be  too  strongly  insisted  on.  Harshness  towards  a  patient  is  always 
to  be  condemned,  and  in  no  disease  more  than  in  this.  By  gentle- 
ness and  a  little  tact,  much  of  the  repugnance  to  the  ojDcration,  on 
the  part  of  friends,  may  be  prevented. 

The  formulae  recommended  in  the  topical  treatment  of  the  larynx 
in  croup  are  proper  for  the  pharynx  as  well  as  larynx  in  diphtheria. 
For  these  formulae  the  reader  is  referred  to  the  article  on  croup. 
The  tincture  of  the  chloride  of  iron  has  been  advantageously 
prescribed  as  a  gargle  with  chlorate  of  potash  in  those  old  enough 
to  employ  such  treatment.  For  this  purpose  a  drachm  of  the  tinc- 
ture should  be  added  to  a  tablespoonful  of  a  saturated  solution  of 
chlorate  of  potash,  and  gargled  every  hour  or  two.  I  prefer,  how- 
ever, a  gargle  consisting  of  carbolic  acid,  six  or  eight  drops  to  one 
ounce  of  solution  of  chlorate  of  potassa,  particularly  if  there  is 
decomposition  of  the  pseudo-membrane  and  an  offensive  odor.  The 
local  treatment  should,  of  course,  vary  according  to  the  extent  and 
character  of  the  inflammation.  When  the  pseudo-membrane  is 
removed,  and  the  inflammation  has  begun  to  abate,  there  is  less 
need  of  active  topical  measures.    They  should  soon  be  discontinued. 

When  croupy  cough  is  observed  in  diphtheria,  it  is  well  to 
administer,  if  the  patient  is  robust,  an  emetic  which  causes  the 
least  possible  prostration.  The  sulphate  of  copper  or  of  zinc  is 
one  of  the  best  emetics  of  this  class.  At  the  same  time  general 
sustaining  treatment  is  required.  Quinine  is  given  by  many  prac- 
titioners when  croup  supervenes,  in  sufficient  quantity  to  reduce 
the  frequency  of  the  pulse.  A  child  from  three  to  five  years  old 
may  take  a  grain  every  two  hours.  I  know  no  better  medicine 
for  such  cases,  though,  unfortunately,  with  this  or  any  other  treat- 
ment, a  large  proportion  die.  Moisture  in  the  apartment  is  desira- 
ble, as  in  the  treatment  of  true  croup.  If  the  laryngeal  symptoms 
continue  to  increase,  and  the  respiration  becomes  so  embarrassed 
that  livid ity  occurs,  the  propriety  of  tracheotomy  becomes  a  serious 
consideration.  It  is  only  in  exceptional  cases  that  it  saves  life,  but 
it  renders  death  more  easy. 

If  the  patient  has  passed  through  diphtheria,  and  entered  upon 
convalescence,  attention  should  be  given  to  his  hygienic  condition, 
and  often  therapeutic  measures  of  a  tonic  character  are  still  re- 
quired. That  most  interesting  and  important  of  the  sequelae, 
namely,  paralysis,  gradually  abates,  without  special  treatment,  as 
the  tone  of  the  system  is  restored.     Strychnine  may  be  given  or 


PERTUSSIS.  247 

the  galvano-clectric  current  employed,  as  a  means  of  expediting 

recovery.     The  following  will  be  found  a  good  formula  for  those 

affected  with  paralysis: — 

I^.  Strychnife  gr.  j ; 

Acid,  pliosphor.  dilut.  5ij ; 
Syr.  zingib.  ^vj.     Misce. 
Dose,  three  to  five  drops  in  a  dessertspoonful  of  water  three  times  daily  to  a 
child  of  three  years. 

The  anaemic  state  which  succeeds  diphtheria  requires  the  use  of 
iron  for  several  weeks. 


CHAPTER   II. 

PERTUSSIS. 

Pertussis,  or  hooping-cough,  is  a  contagious  disease.  It  is 
manifested  by  inflammation  of  the  mucous  membrane  of  the  air- 
passages,  and  a  spasmodic  cough  to  which  this  inflammation  gives 
rise.  It  is  due  to  a  specific  cause,  a  materies  rnorbi,  the  exact  nature 
of  which  is  not  known.  It  may  occur  both  in  the  epidemic  and 
sporadic  form.  It  is  probably  not  inoculable,  although  it  is  highly 
infectious,  either  through  the  breath  of  the  patient,  or  by  exhala- 
tions from  his  surface.  With  rare  exceptions,  it  afl:ects  the  same 
individual  but  once.  Rilliet  and  Barthez  report  a  case  of  its 
second  occurrence,  and  a  case  is  also  reported  by  Dr.  West.  I  have 
never  attended  a  patient  in  two  attacks,  though  I  can  recall  to 
mind  two  individuals,  both  women  of  intelligence,  who  stated  that 
they  had  previous  attacks  in  early  life.  It  occasionally  afi:ects 
young  infants,  even  those  less  than  one  month  old;  and,  on  the 
other  hand,  adults,  and  rarely  even  old  people;  but  most  cases  are 
between  the  ages  of  one  and  seven  years. 

Symptoms. — Pertussis  consists  of  three  stages:  first,  the  ca- 
tarrhal ;  secondly,  the  stage  of  spasmodic  cough — or,  for  brevity, 
the  spasmodic  stage ;  thirdly,  the  stage  of  decline. 

The  first  period  is  characterized  by  the  symptoms  of  coryza  and 
bronchitis.  The  eyes  present  a  moderatel}^  suff'used  and  injected 
appearance.  There  is  sneezing,  with  defluxion  from  the  nostrils  ; 
and  there  is  also  more  or  less  cough,  dependent  on  bronchitic  in- 
flammation. The  cough  does  not  differ  in  character  from  that  in 
the  first  stages  of  simple  bronchitis,  and  there  is  little  or  no  ex- 


248  PERTUSSIS. 

pectoration.  Trousseau  has  known  the  cough  to  be  repeated  forty 
or  fifty  times  per  minute ;  but  such  great  frequency  is  rare.  The 
pulse  and  respiration  are  moderately  accelerated,  and  such  other 
symptoms  as  commonly  accompany  inflammatory  aiiections  of  a 
mild  grade  are  present,  namely,  increased  heat  of  surface,  thirst, 
and  impaired  appetite. 

The  duration  of  the  first  stage  is  various.  It  may,  in  rare  in- 
stances, last  only  two  or  three  days ;  or,  on  the  other  hand,  be  pro- 
tracted even  to  six  weeks.  Its  ordinary  duration  is  from  eight  to 
fifteen  days.  In  fifty-five  cases  observed  by  Dr.  West,  its  average 
duration  was  twelve  days  and  seven-tenths  of  a  day.  I  have  met 
two  cases,  both  girls  over  the  age  of  six  years,  in  whom  no  spas- 
modic cough  was  noticed.  If  there  was  any,  it  was  limited  to  a 
few  paroxysms,  and  it  might,  therefore,  be  said  that  there  was  but 
one  stage,  namely,  the  catarrhal.  They  had  the  symptoms  of  the 
catarrhal  stage,  but  instead  of  the  occurrence  of  the  spasmodic 
cough  at  the  usual  period,  the  inflammatory  symptoms  abated 
somewhat,  and  there  remained  an  occasional  easy  cough,  like  that 
of  simple  subacute  bronchitis.  This  continued  during  a  period 
which  corresponded  with  the  duration  of  pertussis.  The  diagnosis 
in  these  cases  would  have  been  doubtful,  except  for  the  simultane- 
ous occurrence  of  pertussis,  with  its  regular  stages,  in  other  children 
of  the  same  families. 

Second  Period. — This  supervenes  gradually.  At  first,  while  the 
cough  ordinarily  has  the  character  presented  in  the  first  stage,  it  is 
now  and  then  observed  to  be  more  severe  and  spasmodic.  The 
spasmodic  element  increases  gradually,  so  that  in  the  course  of  a 
week  all  doubt  as  to  the  nature  of  the  disease,  if  any  previously 
existed,  is  removed. 

The  severity  of  the  cough  in  the  second  stage  varies  considerably 
in  difterent  cases.  It  sometimes  occurs  quite  abruptly,  but  com- 
monly there  is  premonition  of  it.  The  patient  endeavors  to  re- 
press it.  If  a  child,  he  leaves  his  playthings,  and  rests  his  head  on 
Lis  mother's  lap,  or  takes  hold  of  some  firm  object  for  support;  his 
face  has  a  grave  or  even  anxious  appearance,  while  the  pulse  and 
respiration  are  somewhat  accelerated.  Immediately  the  cough 
commences.  It  consists  in  a  succession  of  short  and  hurried  expi- 
rations, which  expel  a  large  part  of  the  air  contained  in  the  lungs, 
followed  by  a  rapid  and  deep  inspiration.  There  may  be  a  single 
series  of  expirations,  terminating  in  the  manner  mentioned ;  but 
often  there  are  two,  three,  or  more  such  series  embraced  in  a 
paroxysm.     The  paroxysm  commonly  ends   in   the   expulsion  of 


SECOND    PERIOD.  2i9 

frothy  mucus  from  the  bronchial  tubes,  and  sometimes  in  vomiting. 
The  rapid  passage  of  air  through  tlie  glottis,  in  the  inspiration 
which  terminates  the  cough,  is  sometimes  accompanied  by  a  sound, 
which  is  called  the  hoop.  During  the  cough  there  is  temporary 
arrest  of  blood  in  the  lungs,  leading  to  congestion  in  the  right  cavi- 
ties of  the  heart  and  throughout  the  systemic  circulation ;  there- 
fore the  face  is  flushed  and  swollen,  and  occasionally  hemorrhage 
occurs  under  the  conjunctiva,  or  from  one  of  the  mucous  surfaces. 
The  most  frequent  hemorrhage  is  epistaxis.  When  the  cough 
ceases,  and  normal  respiration  is  restored,  the  fulness  of  the  vessels 
immediately  abates  ;  but  often  pufiiness  of  the  features  is  observed, 
due  to  serous  infiltration  of  the  subcutaneous  cellular  tissue,  and 
continuing  for  days  or  weeks  during  the  period  when  the  cough  is 
most  severe. 

The  paroxysm  lasts  from  a  quarter  to  a  half  or  even  a  whole 
minute,  and  in  that  time,  in  severe  cases,  there  are  often  as  many 
as  fifteen  to  twenty  series  of  expirations.  The  hoop  is  not  as  loud 
in  infants  as  in  children,  and  in  young  infants,  especially  those 
under  the  age  of  six  months,  it  is  often  lacking,  although  the  cough 
may  be  severe. 

At  the  close  of  the  paroxj'-sm,  if  there  is  no  complication,  the 
symptoms  soon  abate ;  the  temperature,  pulse,  and  respiration 
become  normal,  and  there  is  no  evidence  of  disease.  The  cough  in 
the  second  stage  is  much  more  frequent  in  one  case  than  another. 
At  the  height  of  this  stage  it  is  generally  more  severe  if  it  occurs 
at  long  intervals  than  when  frequent.  During  the  weeks  in  which 
pertussis  is  most  severe  there  is,  in  the  average,  about  one  paroxysm 
of  coughing  to  each  hour. 

The  cough  increases  in  severity  till  the  third  week  of  the  second 
stage,  or  the  thirtieth  to  thirty-fifth  day  of  the  disease,  after  which 
it  remains  stationary  for  a  certain  time.  It  is  apt  to  be  more 
frequent  in  the  night  than  daytime.  Sometimes  it  occurs  while 
the  child  is  quiet ;  it  may  even  awaken  him  from  sleep,  but  it  is 
often  also  produced  by  mental  excitement  or  by  physical  exertion. 
Anger  or  fright  gives  rise  to  it,  and  therefore  the  child  is  apt  to 
cough  when  being  examined  by  the  physician,  or  when  his  wishes 
are  not  complied  with.  The  ordinary  duration  of  the  second  stage 
is  from  thirty  to  sixty  days.  It  may,  however,  be  considerably 
longer  or  shorter  than  this. 

The  third  stage,  which  commences  at  the  time  when  the  spas- 
modic cough  begins  to  abate,  is  short,  not  continuing  longer  than 
two  or  three  weeks.     A  protracted  stage  of  decline  indicates  some 


250  PERTUSSIS. 

complication.  While  the  sputum  in  the  second  stage  is  mucous 
and  frothy,  that  in  the  third  stage  is  more  opaque  and  puriform. 

In  the  third  as  in  the  second  stage,  if  there  is  no  complication, 
the  pulse  and  respiration  in  the  intervals  of  the  paroxysms  are 
nearly  or  quite  natural.  Febrile  excitement  may,  however,  now 
and  then  occur  from  trifling  causes,  or,  indeed,  without  any  appa- 
rent cause.  The  digestion  and  the  general  health  in  uncompli- 
cated pertussis  remain  unimpaired,  with  the  exception  of  more  or 
less  emaciation,  which  is  apt  to  occur  in  all  hut  the  mildest  cases, 
in  consequence  of  the  frequent  vomiting.  After  complete  recovery, 
it  is  not  unusual  for  the  spasmodic  cough  to  reappear,  at  times,  for 
one  or  even  two  years.  The  cough  of  ordinary  simple  laryngitis, 
or  bronchitis,  assumes  this  character. 

CoMPLiCATioxs. — These,  like  the  symptoms,  are  chiefly  of  a  two- 
fold character,  namely,  inflammatory  and  neuropathic.  From  the 
nature  of  the  cough  in  this  disease,  it  would  naturally  be  supposed 
that  the  spasmodic  affection,  which  is  now  designated  internal 
convulsions,  and  which  is  characterized  by  spasm  of  certain  muscles 
of  respiration,  would  be  a  frequent  complication.  It  does  sometimes 
occur  in  young  children,  but  it  is  not  common.  Clonic  convulsions 
affecting  the  external  muscles  are,  on  the  other  hand,  not  infre- 
quent. They  occur  chiefly  in  the  second  stage,  when  the  cough  is 
most  severe,  and  in  infancy  much  more  frequently  than  in  child- 
hood. They  are  apt  to  be  general  and  severe,  or,  if  not  of  this 
character  at  first,  to  become  such.  The  convulsions  commence,  in 
most  instances,  in  or  directly  after  the  paroxysm  of  coughing ;  but 
they  sometimes  occur  in  the  interval  when  the  child  is  quiet. 

Rilliet  and  Barthez  remark :  "  Almost  all  infants  succumb  to 
this  complication,  ordinarily  in  the  twenty-four  hours  which  follow 
the  first  attack ;  nevertheless,  life  may  be  prolonged  during  two  or 
three  days"  (Article  Coqueluche).  In  my  own  practice  this  compli- 
cation of  hooping-cough  has  usually  terminated  fatally,  but  I  have 
known  recovery  to  occur  somewhat  unexpectedly  under  the  use  of 
bromide  of  potassium.  In  the  month  of  June,  1867, 1  was  attend- 
ing a  little  girl  two  years  and  four  months  old,  who  had  reached 
the  fifth  week  of  pertussis,  when  she  was  seized  with  general  clonic 
convulsions.  The  mother,  who  was  requested  to  keep  a  record  of 
the  number  of  convulsions,  stated  that  there  were  twenty  in  all, 
occurring  within  forty-eight  hours.  They  affected  both  sides,  the 
shortest  lasting  only  three  or  four  minutes,  the  longest  seventy-five 
minutes.  The  treatment  in  this  case,  which  eventuated  favorably, 
will  be  noticed  hereafter. 


COMPLICATIONS.  251 

111  those  wlio  die  of  convulsions  occurring  in  hooping-cough, 
the  most  constant  lesion  is  congestion  of  the  cerebral  veins  and 
sinuses,  often  with  transudation  of  serum.  This  congestion  is  due 
in  part  to  the  cough  which  precedes  the  convulsions,  and  in  part  to 
the  convulsions  themselves.  At  the  autopsies  which  I  have  made 
of  two  infants,  who  died  in  hospital  practice  from  hooping-cough, 
accompanied  by  convulsions,  all  the  cerebral  sinuses  were  filled 
with  clots,  which  were  generally  soft  and  dark ;  but  in  the  lateral 
sinuses  clots  were  found,  which  were  light-colored.  The  light 
color  of  a  clot,  either  in  a  vein  or  sinus,  indicates  its  ante-mortem 
formation. 

The  gravity  of  the  convulsive  attack  can  be  ascertained  by  ob- 
serving whether  the  patient  readily  recovers  consciousness.  Its 
return  indicates  that  there  is  no  serious  congestion.  On  the  other 
hand,  great  drowsiness  remaining,  or  a  semi-comatose  state,  indi- 
cates persistent  congestion,  and  perhaps  even  the  formation  of  clots 
in  the  sinuses  of  the  brain.  Death  from  convulsions  is  usually 
preceded  by  coma.  Occasionally  meningeal  apoplexy  supervenes 
upon  the  congestion,  and  death  is  immediate. 

The  most  frequent  inflammatory  complications  are  bronchitis 
and  pneumonitis.  Inflammation  of  the  larger  bronchial  tubes,  we 
have  seen,  is  a  common  accompaniment  of  pertussis,  but  when  it 
extends  to  the  minuter  tubes,  or  becomes  so  severe  as  to  cause 
acceleration  of  respiration,  it  is,  properly,  a  complication.  Both 
bronchitis  and  pneumonitis,  occurring  as  complications,  are  de- 
veloped, with  few  exceptions,  in  the  second  stage.  Bronchitis 
is  accompanied  by  accelerated  respiration  and  pulse,  and  increased 
temperature.  The  danger  is  proportionate  to  the  amount  of 
dyspnoea. 

Pneumonitis  is  a  less  common  complication  than  bronchitis,  but 
it  occurs  more  frequently  in  pertussis  than  in  any  other  constitu- 
tional aftection  of  early  life,  excepting  measles.  The  congestion, 
which  occurs  and  remains  in  the  lung  when  the  cough  is  frequent 
and  severe,  favors  the  development  of  pneumonia.  The  symptoms 
and  physical  signs  which  accompany  this  inflammation  and  serve 
for  its  diagnosis  are  the  same  as  in  the  primary  form  of  the  dis- 
ease, and  are  described  elsewhere.  Bronchitis  or  pneumonia  usually 
moderates  the  severity  of  the  spasmodic  cough,  for  when  the  inflam- 
matory element  in  pertussis  increases,  the  spasmodic  abates.  On 
the  abatement  of  the  inflammation,  however,  the  cough  usually 
regains  its  former  convulsive  character.  The  fact  may  be  stated 
in  this  connection,  that  any  complication  or  intercurrent  disease, 


252  PERTUSSIS. 

which  is  attended  by  decided  febrile  reaction,  ordinarily  renders 
the  cough  for  the  time  less  spasmodic. 

The  occurrence  of  bronchitis  or  pneumonia  is  shown  by  the 
elevated  temperature,  acceleration  of  pulse  and  respiration,  short 
and  frequent  cough.  These  symptoms  do  not  cease  as  long  as  the 
inflammation  continues,  whereas  in  uncomplicated  pertussis  the 
patient  seems  nearly  or  quite  well  between  the  coughs.  In  pneu- 
monia the  respiration  is  accompanied  by  the  expiratory  moan,  and 
in  both  bronchitis  and  pneumonia  there  is  more  or  less  depression 
of  the  infra-mammary  region  during  inspiration.  These  symptoms, 
in  connection  with  the  physical  signs,  render  diagnosis  in  most 
instances  easy.  Although  the  general  character  of  the  cough  is 
changed,  a  cough  now  and  then  occurs,  even  when  the  inflamma- 
tion is  pretty  severe,  sufliciently  spasmodic  to  indicate  the  nature 
of  the  primary  afl'ection.  Capillary  bronchitis  and  pneumonia  are 
always  serious  complications. 

It  is  stated  by  certain  writers  that  the  spasmodic  cough  of  per- 
tussis occasionally  gives  rise  to  emphysema,  and  dilatation  of  the 
bronchial  tubes.  Rilliet  and  Barthez  do  not  believe  that  these 
structural  changes  occur  from  such  a  cause,  because  the  spasmodic 
character  of  the  cough  of  pertussis  pertains  to  expiration.  Later 
observations,  however,  demonstrate  that  emphysema  in  certain 
cases  does  result  from  forcible  expirations  (Niemeyer  and  others). 
Emphysema  is  a  common  lesion  in  young  and  feeble  infants,  even 
when  there  is  no  history  of  any  previous  severe  disease  of  the 
respiratory  organs.  I  have  found  it  one  of  the  most  common  lesions 
in  infants  of  feeble  constitutions  who  die  in  the  Infant's  Hos- 
pital and  ISTursery  and  Child's  Hospital  of  this  city.  The  chief 
cause  of  the  emphysema  in  these  cases  appears  to  be  the  impaired 
nutrition  and  chano-e  in  the  molecular  condition  of  the  tissues. 
The  same  condition  arises  in  severe  and  protracted  pertussis,  in 
which  the  child  becomes  enfeebled  and  cachectic.  If  severe  bron- 
chitis arises,  we  have  still  another  factor  in  the  production  of 
emphysema. 

At  the  meeting  of  the  New  York  Pathological  Society,  October 
14th,  1868,  I  exhibited  emphysematous  lungs  removed  from  an 
infant  who  died  at  the  age  of  nineteen  months,  and  at  the  com- 
mencement of  the  fourth  week  of  pertussis.  Death  occurred  from 
thrombosis  in  the  lateral  sinuses  of  the  cranium,  resulting  from 
the  severe  spasmodic  cough,  clonic  convulsions,  and  from  feebleness 
of  the  circulation,  as  the  infant  was  previously  in  a  reduced  state 
from  chronic  entero-colitis.     At  the  autopsy  the  superior  lobes  of 


DIAGNOSIS.  253 

both  lungs  were  found  exsanguine,  doughy  to  the  feel,  and  enlarged 
80  as  to  rise  above  the  level  of  the  other  lobes.  The  resiliency  of 
the  elastic  tissue  of  those  lobes  was  evidently  greatly  impaired, 
and  their  air-cells  in  a  state  of  over-distension.  The  other  lobes 
were  healthy,  except  that  one  of  them  was  the  seat  of  lobular 
pneumonia.  In  the  history  of  this  case  it  did  not  appear  that 
there  had  been  any  pathological  state  affecting  the  respiratory 
system  previousl}^  to  the  pertussis,  so  that  the  commencing  emphy- 
sema was  referable  to  this  disease.  The  forcible  and  irregular  res- 
pirations  which  accompany  the  cough  of  pertussis  appear,  there- 
fore, sufficient  for  the  production  of  emphysema  in  the  infant. 

I  have  occasionally  met  cases  in  which  partial  collapse  of  certain 
portions  of  the  lungs  had  occurred,  and  the  mechanism  of  the  cough 
is  such  that  this  would  be  a  more  probable  result  than  enlargement 
of  either  the  tubes  or  air-cells.  Collapse,  like  emphysema,  may 
continue  for  weeks  or  months  subsequently  to  pertussis,  and  then 
gradually  disappear. 

Diagnosis. — During  the  period  of  invasion  it  is  impossible  to 
diagnosticate  pertussis.  Its  nature  can  only  be  conjectured  from  a 
known  exposure,  or  from  the  epidemic  occurrence  of  the  disease. 
In  the  second  stage,  which  is  characterized  by  the  spasmodic 
cough,  diagnosis  is  ordinarily  easy,  and  often  the  parents  are  able 
to  announce  the  nature  of  the  disease  when  the  phj^sician  is  called. 
Still,  a  mistake  is  sometimes  made:  a  spasmodic  cough  very  similar 
to  that  of  pertussis  occasionally  occurs  in  other  maladies.  Young 
infants  with  bronchitis  frequently  experience  great  difficulty  in 
the  expectoration  of  mucus,  which  collects  in  the  air-passages  and 
provokes  a  suffocative  cough.  The  following  facts  will  aid  in 
making  the  diagnosis.  Bronchitis,  accompanied  by  a  suffocative 
cough,  is  an  acute  disease,  and  the  cough  occurs  at  an  early  period, 
usually  in  the  first  week.  It  lacks  the  inspiratory  sound  or  the 
hoop,  and  is  associated  with  constantly  accelerated  respiration  and 
well-marked  febrile  symptoms,  dependent  on  the  inflammation. 
Moreover,  the  cough  is  only  occasionally  suffocative,  according  to 
the  amount  of  mucus  in  the  tubes.  The  spasmodic  cough  of  jDcr- 
tussis,  on  the  other  hand,  is  preceded  by  the  stage  of  invasion. 
This  cough  occurs  in  the  second  stage,  when  the  febrile  symptoms 
have  abated;  if  the  disease  is  uncomplicated,  it  is  accompanied  by 
a  hoop,  and  its  ordinary  character  is  spasmodic.  Again,  the  suffo- 
cative cough  of  bronchitis  rarely  ends  in  vomiting,  which  has  been 
seen  to  be  so  common  in  the  cough  of  pertussis. 

The  only  other  disease  with  which  there  is  much  likelihood  of 


254  PERTUSSIS. 

confounding  pertussis  is  bronchial  phthisis.  The  points  of  differ- 
ential diagnosis  are  the  following:  the  one  epidemic,  and  spreading 
by  contagion;  the  other  non-contagious,  and  isolated:  the  one  em- 
braced in  three  distinct  stages,  and  much  shorter;  the  other  chronic, 
and  presenting  no  stages,  but  commencing  with  mild  non-febrile 
symptoms,  and  progressively  becoming  more  severe :  in  the  one  an 
absence  of  symptoms  in  the  intervals  of  the  cough,  provided  there 
is  no  complication;  in  the  other  constant  symptoms,  such  as  are 
common  in  tubercular  disease.  The  previous  health,  and  the  pre- 
sence or  absence  of  a  tubercular  cachexia,  should  be  considered  in 
determining  the  nature  of  the  disease,  and  usually,  in  bronchial 
phthisis,  the  lungs  are  also  affected,  so  that  auscultation  and  per- 
cussion may  furnish  positive  proof  of  the  nature  of  the  cough. 

Prognosis. — This  is  ordinarily  favorable.  Xearly  all  recover, 
unless  some  complication  arises.  In  rare  instances  death  may  occur 
in  or  immediately  after  a  paroxysm  of  coughing,  in  consequence 
of  the  rupture  of  cerebral  capillaries,  and  the  occurrence  of  apo- 
plexy. Most  fatal  cases,  however,  are  complicated  with  either 
clonic  convulsions,  bronchitis,  pneumonia,  or,  in  the  summer  season, 
entero-colitis,  and  death  is  due  to  the  complication  rather  than  the 
pertussis.  It  has  been  stated  elsewhere  that  clonic  convulsions 
render  the  prognosis  unfavorable,  but  the  case  detailed  above  shows 
that  some  may  recover.  If  the  convulsion  is  succeeded  by  marked 
drowsiness,  the  prognosis  is  very  unfavorable.  It  is  probable  that 
other  convulsions  will  occur,  ending  in  coma.  Immediate  recovery 
of  consciousness  shows  a  less  dangerous  form  of  convulsions,  and 
one  which,  with  proper  treatment,  may  terminate  favorably. 

The  danger  in  bronchitis  and  pneumonia  depends  on  the  extent 
of  the  inflammation,  the  amount  of  dyspnoea,  the  age  and  strength 
of  the  patient.  Capillary  bronchitis  and  pneumonia  are  always 
serious  complications.  They  have  been  the  cause  of  death  in  a 
large  proportion  of  the  fatal  cases  which  I  have  attended.  Per- 
tussis sometimes  is  attended  with  so  much  emaciation  and  loss  of 
strength,  in  consequence  of  the  vomiting,  that  intercurrent  diseases, 
which,  in  favorable  states  of  the  system,  would  probably  end  favora- 
bly, are  very  apt  to  prove  fatal.  In  this  city  epidemics  of  the  diar- 
rhoeal  affections,  so  common  among  infants  in  the  summer,  are  much 
more  fatal  if  at  the  same  time  there. is  an  epidemic  of  pertussis.  In 
my  practice,  an  infant  affected  at  the  same  time  wdth  the  "  summer 
complaint"  and  hooping-cough  has  generally  perished,  unless  re- 
moved to  the  country.     If  there  is  much  emaciation  and  an  heredi- 


TREATMENT.  255 

tary  tendency  to  tuberculosis,  the  prognosis  is  more  unfavorable, 
on  account  of  the  probable  occurrence  of  this  disease. 

Trp:atment. — In  the  catarrhal  stage  the  treatment  should  be  the 
same  as  in  idiopathic  catarrh.  It  should  consist  of  mild  counter- 
irritation  to  the  chest.  If  there  is  much  bronchitis,  with  accele- 
rated breathing,  the  oil-silk  jacket  may  be  applied.  Demulcent, 
laxative,  and  gentle  expectorant  mixtures  are  proper.  Care  should 
be  taken  to  employ  nothing  which  would  reduce  the  strength,  or 
in  any  way  impair  the  general  health. 

Therapeutic  measures  are  most  beneficial  in  the  second  stage,  or 
that  of  convulsive  cough.  Proper  treatment  may  prevent  or  con- 
trol complications,  which  arise  chiefly  in  this  stage,  and  may  mod- 
erate the  intensity  of  the  cough.  Many  formulae  have  been  recom- 
mended for  the  treatment  of  pertussis,  most  of  them  containing 
some  antispasmodic.  Oxide  of  zinc,  musk,  assafcetida,  valerian, 
cochineal,  the  anaesthetics,  and  many  other  medicinal  agents,  have 
been  employed,  and  there  are  physicians  with  whom  each  of  these 
has  had  its  season  of  repute.  The  three  medicines  which  are  most 
in  favor  with  the  profession,  both  in  this  country  and  Europe,  and 
properly  so,  are  hydrocyanic  acid,  balladonna,  and  bromide  of  am- 
monium. The  employment  of  the  last  of  these  is  comparatively 
recent.  The  others  are  old  remedies,  and  their  therapeutic  effects 
are  more  fully  ascertained.  In  my  opinion,  the  treatment  by  bella- 
donna is  usually  most  successful,  and  this  agent  is  more  employed 
than  any  other.  Some  of  the  belladonna  of  the  shops,  as  is  true 
likewise  of  hydrocyanic  acid,  is  of  inferior  quality,  either  from  its 
mode  of  preparation,  or  the  manner  in  which  it  has  been  kept,  and 
is  therefore  not  reliable.  But  if  good,  and  prescribed  properly,  it 
will  ordinarily  render  the  cough  milder. 

The  first  dose  of  belladonna  should  be  smaller  than  will  probably 
be  required  to  ameliorate  the  disease.  The  child,  however,  requires 
a  larger  proportionate  dose  of  belladonna  than  an  adult  to  produce 
the  same  effect.  Trousseau's  great  experience  in  the  treatment  of 
children's  diseases,  and  his  successful  practice,  render  his  views  in 
reference  to  the  employment  of  this  agent  deserving  of  careful  con- 
sideration. For  young  children  he  directed  pills  to  be  made,  each 
containing  about  one-tenth  of  a  grain  of  extract  of  belladonna 
mixed  with  an  equal  quantity,  of  the  powder  of  the  leaves  of  bella- 
donna. 

For  children  over  the  age  of  four  years,  the  pills  contained  one- 
fifth  of  a  grain  of  the  extract  and  the  same  quantity  of  the  powder. 
He  directed  that  one  of  these  pills  should  be  taken  in  the  morning 


256  PERTUSSIS. 

when  the  stomach  was  empty,  and  a  second  on  the  following  morn- 
ing. The  nurse  marked  on  a  card  each  paroxysm  of  coughing,  so 
that  the  effect  of  the  medicine  could  be  ascertained.  If  the  number 
of  paroxysms  was  diminished,  or  the  cough  rendered  less  severe, 
80  that  there  was  evidently  decided  amelioration,  the  same  dose 
was  administered  each  day.  If,  on  the  other  hand,  there  was  no 
improvement  in  the  number  or  severity  of  the  paroxysms,  two  pills 
were  given  on  the  following  morning,  three  on  the  next,  and  so  on 
till  an  appreciable  effect  was  produced.  Trousseau  considered  it 
important  to  give  at  one  dose  whatever  belladonna  is  administered 
during  the  day.  The  same  quantity  per  day  given  in  small  doses, 
at  intervals,  he  believed  to  be  less  effectual. 

The  dose  which  he  found  to  produce  amelioration  of  the  symp- 
toms he  ordered  to  be  repeated  daily  during  the  succeeding  six  or 
eight  days.  Then,  if  the  improvement  continued,  the  dose  was 
gradually  diminished  by  one  pill  each  day,  back  to  the  first  dose ; 
but  if  the  cough  increased,  the  dose  was  again  increased. 

Finally,  when  the  spasmodic  cough  had  entirely  ceased.  Trous- 
seau advised  the  continuance  of  the  medicine  six  or  eight  days 
longer  before  its  complete  suspension. 

Trousseau  sometimes  employed  atropine  in  place  of  belladonna, 
since  the  medicinal  properties  of  the  plant  reside  in  this  alkaloid, 
and,  being  crystalline,  its  strength  is  always  uniform.  He  gave 
the  neutral  sulphate  of  atropia  in  dose  of  about  j^?  P'^^i't  of  a  grain, 
dissolved  in  distilled  water,  to  infants  or  young  children,  in  the 
same  manner  as  he  prescribed  belladonna.  For  older  children  he 
ordered  a  dose  proportionately  larger.  Brown-Sequard,  in  remarks 
made  before  the  United  States  Medical  Association  in  May,  1866, 
maintained  that  the  duration  of  pertussis,  so  far  as  the  neuropathic 
element  is  concerned,  might  be  abridged  to  a  few  days  by  doses  of 
atropia  sufficiently  large  to  produce  toxical  effects.  He  recom- 
mends a  dose  which  will  cause,  and  repeated  will  maintain,  deli- 
rium for  three  days;  after  which,  he  states,  the  cough  is  no  longer 
spasmodic. 

The  older  physicians  who  first  advised  the  employment  of  bel- 
ladonna in  pertussis,  as  Schacffer,  Guersant,  Goclis,  and  Wcndt, 
used  it  with  caution,  and  in  small  or  moderate  doses,  apparently 
believing  that  its  use  involved  considerable  danger.  It  is  now, 
however,  considered  a  safe  as  well  as  eflUcient  remedy,  and  it  is 
admitted  that  in  pertussis  the  full  benefit  of  the  drug  can  only  be 
obtained  from  doses  which  produce  a  decided  impression  on  the 
system.     If  there  is  no  amelioration  of  symptoms  from  smaller 


TREATMENT.  257 

doses,  it  is  proper  to  give  it  in  a  quantity  which  will  cause  dry- 
ness of  the  fauces  and  eiHorescence  U2:)on  the  skin. 

The  tincture  of  belladonna  is  most  convenient  for  use.  The  doses 
which  I  have  found  to  be  sufficient  to  modify  the  cough,  at  the 
same  time  producing  efflorescence,  are  as  follows:  To  a  child  of  two 
years  three  drops,  to  one  of  six  to  eight  years  ten  drops,  morning 
and  evening.  I  always  commence,  however,  with  a  smaller  dose, 
and  continue  to  administer  for  a  few  days  the  dose  which  is  found 
to  produce  the  local  eiiects  alluded  to.  In  the  majority  of  cases 
I  have  noticed  no  decided  effect  till  the  rash  was  produced,  when 
the  symptoms  improved,  the  cough  becoming  either  less  frequent  or 
less  severe.  I  have  by  means  of  this  treatment  been  able  to  curtail 
the  duration  of  the  disease  to  four  weeks  from  the  beg-innins:  of 
the  catarrhal  stage,  even  when  the  paroxysms  were  unusually 
severe.  The  dose  which  proves  sufficient  to  control  the  disease 
should  be  administered  daily  for  a  time,  and  then  gradually  di- 
minished as  the  cough  declines.  Hydrocyanic  acid  possesses  the 
power  of  controlling  the  spasmodic  cough  of  pertussis.  It  is  re- 
commended by  Dr.  West.  "  I  usually  begin,"  says  he,  "  with  a 
dose  of  half  a  minim  of  the  acid  of  the  London  Pharmacoposia 
(that  of  the  U.  S.  Ph.  is  the  same)  every  four  hours  for  a  child  nine 
months  old ;  and  so  in  proportion  for  older  children.  The  specific 
influence  of  the  remedy  is,  I  think,  both  more  safely  and  efficiently 
exerted  by  increasing  the  frequency  of  its  administration  than  by 
adding  to  the  dose,  and  I  should  therefore  prefer  to  give  half  a 
dose  every  two  hours,  rather  than  to  double  the  dose  without  in- 
creasing the  frequency  of  its  repetition.  This  remedy  sometimes 
exerts  an  almost  magical  influence  on  the  cough,  diminishing  the 
frequency  and  severity  of  its  paroxysms  almost  immediately ;  while 
in  other  cases  it  seems  perfectly  inert."  Dr.  AVest  has  employed 
this  remedy  several  hundred  times,  and  only  once  has  observed 
alarming  symptoms  from  its  use.  The  patient  was  two  and  a  half 
years  old,  and  had  been  ordered  one  minim  of  the  dilute  acid 
every  four  hours.  He  took  the  acid  for  four  days  without  any 
effect  being  produced,  either  on  his  system  generally,  or  on  the 
cough ;  but  at  the  end  of  that  time,  after  taking  the  dose,  he  ut- 
tered a  cry,  became  quite  faint,  and  would  have  fallen,  if  not  sup- 
ported. 

Hydrocyanic  acid,  given  in  safe  doses,  does  not  appear  to  pro- 
duce amelioration  of  symptoms  in  so  large  a  proportion  of  cases  as 
belladonna,  and  I  do  not  know  any  advantages  which  it  possesses 
over  that   agent.     Belladonna  never  produces   sudden  alarming 
17 


258  PERTUSSIS. 

symptoms,  like  the  acid.  If,  throngli  mistake,  more  than  the  pre- 
scribed quantity  is  administered,  it  may  cause  delirium,  and  the 
characteristic  eftect  on  the  mucous  membrane  of  the  fauces  and 
upon  the  skin;  but  a  gradual  disax»pearance  of  these  symj^toms 
may  be  confidently  expected,  without  any  injury  to  the  patient. 
Even  poisonous  doses,  unless  excessive,  are  rarely  fatal.  If  for  any 
reason  it  is  thought  best  to  prescribe  hydrocyanic  acid,  the  fol- 
lowing formulae  from  "West  may  be  employed: — 

R.  Acid,  liydrocy.  dil.  ^.iv  ; 
Syrupi  simplicis  5J  ; 
Aqufe  destillat.  3'^ij-     ^^■ 
A  teaspoonful  to  be  taken  every  six  hours  by  a  child  nine  months  old. 

R.  Acid,  hydrocy.  dilut.  iTLiv ; 
Mistur.  amygdalae  5j.     M. 
Dose  the  same. 

The  bromides  have,  within  a  few  years,  been  used  in  the  treat- 
ment of  pertussis.  They  were  first  recommended  by  Br.  Gibbs, 
and  subsequently  by  Prof.  Harley,  of  London.  It  is  claimed  for 
them  that  they  produce  an  auajsthetic  efiect  on  the  mucous  mem- 
brane of  the  larynx.  The  bromide  employed  by  the  above  and 
other  physicians  has  commonly  been  that  of  ammonium,  but 
some  prescribe  that  of  iwtassium,  or  the  two  in  combination. 
Prof.  Harley  gives  one  grain  of  the  bromide  of  ammonium  for 
each  year  of  the  patient's  age,  three  times  daily ;  Dr.  Gibbs  gives 
two  or  three  grains  every  eight  hours  to  infants,  and  from  four  to 
ten  grains  to  older  children.  Dr.  Ritchie,  physician  to  the  Royal 
Edinburgh  Hospital  for  Sick  Children,  says  of  it  {Edin.  31ed.  Journ., 
June,  1864):  "In  my  experience,  the  remedy  appears  to  be  most 
successful  in  children  whose  age  exceeds  two  years.  .  .  .  The  quan- 
tity I  have  generally  given  has  been  from  three  to  twelve  grains 
a  day,  in  divided  doses,  administered  every  six  hours.  .  .  .  Having 
used  the  preparation  in  upwards  of  twenty  cases,  if  I  may  be 
allowed  to  express  an  opinion  on  this  head,  it  would  be  that  the 
great  efficacy  of  the  drug  is  in  uncomplicated  cases;  that  in  those 
complicated  with  acute  bronchitis,  or  pneumonia,  the  benefit  is  so 
trifling  that  I  prefer  other  methods  of  treatment;  for  an  acute 
congested  condition  of  the  air-passages  appears  to  lessen  the  eftect 
of  the  bromide  as  a  laryngeal  anaesthetic ;  that  the  more  frequent 
the  paroxysms  of  hooping,  the  more  marked  and  rapid  is  the  relief; 
that  greater  relief  appears  to  be  experienced  in  those  of  some 
continuance  than  in  recent  cases;  and,  lastly,  that  when  chronic 
bronchitis  is  present,  the  bromide  should  not  be  given  alone,  but 


TREATMENT.  259 

combined  with  squill  and  ipccacuaidia  mixture,  and  occasionally 
with  an  emetic." 

I  have  employed  the  bromides,  though  not  largely,  in  the  treat- 
ment of  pertussis,  but  have  not,  in  ordinary  cases,  observed  that 
benefit  which  I  had  been  led  to  expect.  In  recent  cases,  belladonna 
is  a  much  more  efficient  remedy.  I  would  use  the  bromides  chiefly 
in  advanced  cases,  and  in  cases,  whatever  the  period  of  pertussis, 
in  which  there  seems  to  be  imminent  danger  of  clonic  convulsions. 
In  these  last  cases,  the  bromide  of  potassium,  with  or  without 
that  of  ammonium,  may,  in  certain  cases,  prevent  the  convulsive 
seizure.  The  hydrate  of  chloral  has  been  employed  for  pertussis, 
in  the  children's  class,  in  the  out-door  department  at  Bellevue. 
It  produces  prolonged  sleep,  and  consequently  diminishes  the  fre- 
quency of  the  cough  as  long  as  the  narcotic  effect  lasts,  otherwise 
it  does  not  seem  to  exert  any  influence  on  the  symptoms  or  progress 
of  the  disease. 

There  are  many  other  remedies  which  have  been  vaunted  in  the 
treatment  of  pertussis,  and  which  do  moderate  the  severity  of  the 
cough.  Some,  it  seems  to  me,  have  this  effect  by  producing  febrile 
excitement.  Such  is  the  use  of  cantharides,  so  as  to  produce  active 
congestion  of  the  urinary  passages  and  strangury;  severe  counter- 
irritation  over  the  chest  by  tartar  emetic,  namely,  Autenrieth''s 
treatment,  etc.  Emetics  have  sometimes  been  prescribed  in  the  first 
stage  of  pertussis,  in  the  belief  that  they  moderated  the  severity 
of  the  disease.  They  are  more  frequently  employed  on  the  Conti- 
nent than  in  this  country.  Laennec  says:  "j^ot  any  measure  is 
more  useful  in  the  commencement  of  pertussis  than  vomiting, 
repeated  every  day  or  every  two  days,  during  one  or  two  weeks." 
Some  physicians  have  given  for  this  purpose  ipecacuanha,  and 
others  sulphate  of  zinc.  Trousseau  employed  sulphate  of  copper. 
The  loss  of  strength,  however,  which  necessarily  attends  the  em- 
ployment of  emetics,  even  the  mildest,  more  than  counterbalances 
any  good  effect  of  their  use,  except  when  there  is  considerable 
accumulation  of  mucus  in  the  tubes,  which  an  emetic  assists  in 
expelling. 

A  remedy  long  in  use,  and  still  a  favorite  with  many  families, 
consists  of  half  a  scruple  of  cochineal,  one  scruple  of  carbonate  of 
potassa,  one  drachm  of  sugar,  and  four  ounces  of  water.  The  dose 
for  a  child  one  year  old  is  a  dessertspoonful  three  times  daily ;  for 
older  children  the  dose  is  increased  in  a  corresponding  degree.  It 
is  believed  by  some  that  the  cochineal  is  inert,  and  that  the  bene- 


260  PERTUSSIS. 

ficial  effect  of  the  above  mixture  is  due  to  the  potassa,  which 
modifies  the  accompanying  bronchitis. 

Alum,  in  doses  of  one  to  six  grains,  according  to  the  age,  is 
recommended  by  Dr.  J.  F.  Meigs  {Treatise  on  Diseases  of  Children). 
Inhalation  of  the  fumes  arising  from  the  purification  of  gas,  has 
been  recommended  in  Paris  as  an  effectual  remedy  in  the  declining 
stage  of  pertussis;  but,  on  the  other  hand,  it  is  alleged  that  the 
benefit  is  due  to  the  out-door  exercise  required  by  this  treatment. 
M.  Eoger  employed  these  fumes  in  the  wards  of  the  Children's  Hos- 
pital, Paris ;  but  apparently  without  benefit.  IS^itric  acid  has  also 
been  used  internally,  and  applications  of  nitrate  of  silver  to  the 
throat;  both,  it  is  stated,  with  improvement  in  certain  cases. 
Change  of  air  is  always  beneficial  in  advanced  hooping-cough.  In 
uncomplicated  cases  the  child  should  be  carried  daily  into  the  open 
air;  but,  on  account  of  the  inflammatory  affection  of  the  air-pas- 
sages, should  never  be  exposed  to  cold  or  wet,  or  sudden  changes  of 
temperature.  For  the  same  reason  the  temperature  of  the  apart- 
ment should  be  moderately  warm  and  uniform.  Great  benefit,  as 
regards  the  severity  of  the  cough,  often  accrues,  especially  in  the 
advanced  period  of  the  disease,  by  removing  the  child  to  the  coun- 
try, or  to  another  locality. 

Severe  bronchitis,  or  pneumonia,  which  often  complicates  per- 
tussis, requires  the  treatment  which  is  elsewhere  recommended  for 
the  secondary  form  of  this  inflammation,  namely,  the  use  of  the 
oil-silk  jacket,  poultices,  counter-irritation,  and,  internally,  carbon- 
ate of  ammonia,  with  perhaps  a  tonic.  As  mild  bronchitis  is  present 
from  the  commencement  of  the  disease,  the  oil-silk  jacket  is  useful 
even  before  the  inflammation  becomes  so  severe  as  to  constitute  a 
complication.  Clonic  convulsions,  which  we  have  seen  are  a  com- 
mon and  very  serious  complication,  should  be  treated  by  cold  to  the 
head,  a  warm  foot-bath,  and  laxatives  in  certain  cases.  The  medi- 
cine which,  in  my  opinion,  is  most  likely  to  control  the  spasmodic 
movements,  is  bromide  of  potassium.  The  mode  of  administering 
this  agent  will  be  sufficiently  explained  in  our  remarks  relating 
to  the  treatment  of  eclampsia.  In  the  case  alluded  to  in  the  pre- 
ceding pages,  in  which  there  were  twenty  convulsions  within  forty- 
eight  hours,  and  the  patient,  two  years  and  four  months  old, 
recovered,  the  bromide  of  potassium  was  given  in  combination  with 
the  iodide.  The  dose  was  about  two  grains  of  each  every  two  or 
three  hours. 


PAKOTIDITIS.  261 


CHAPTER  V. 

PAROTIDITIS. 

Ordinarily,  parotiditis,  or  parotitis,  or  mumps,  has  no  premo- 
nitory stage;  but  in  exceptional  cases,  languor  with  fever  pre- 
cedes the  disease  for  a  few  hours.  Mumps  commences  with  ten- 
derness in  the  parotid  region,  followed  soon  after  by  tumefaction. 
The  swelling  gradually  increases  ;  it  fills  the  depression  under  the 
ear,  extends  forward  and  upward  upon  the  cheek,  and  downward  to 
a  greater  or  less  extent  upon  the  neck.  It  has  been  demonstrated 
in  case  of  symptomatic  parotiditis,  and  the  same  is  probably  true 
of  the  idiopathic  disease,  or  mumps  (Virchow),  that  the  swelling  is 
due  to  inflammation  of  the  gland-ducts,  and  consequent  cedema  of 
the  interstitial  tissue.  The  inflammation  is  specific,  due  to  a  mate- 
ries  morbi  in  the  blood,  and  hence  its  decline  after  a  fixed  period. 
It  reaches  its  maximum  from  the  third  to  the  sixth  day.  The 
most  prominent  point  at  this  time  is  immediately  underneath  the 
lobule  of  the  ear.  The  tumor,  which  is  firm  but  slightly  elastic, 
presses  outward  the  lobule.  In  most  cases  the  skin  preserves  its 
normal  appearance  over  the  swelling,  but  occasionally  it  presents 
a  faint  blush.  The  pressure  which  movements  of  the  jaw  produce 
on  the  gland  renders  mastication  and  even  talking  painful.  Febrile 
movement  more  or  less  intense  occurs,  lasting,  in  ordinary  cases, 
not  more  than  forty-eight  hours,  but  occasionally  it  is  more  pro- 
tracted. Vomiting  and  epistaxis  are  sometimes  present.  Tlie 
swelling  having  attained  its  maximum  size,  remains  stationary  a 
short  time,  when  it  begins  to  decline,  and  by  the  sixth  to  tenth 
day  it  has  entirely  subsided. 

In  most  cases  parotiditis  is  double ;  it  commences  on  one  side, 
more  frequently  the  left  than  right,  and  in  from  one  to  four  days 
the  opposite  gland  is  involved.  In  those  exceptional  cases  in 
which  only  one  parotid  is  affected,  the  opposite  gland  may  be  the 
seat  of  the  disease  at  some  subsequent  period.  It  has  been  estimated 
that  the  proportion  of  unilateral  to  double  mumps  is  as  one  to  ten. 

Tlie  total  duration  of  this  disease  is  usually  from  eight  to  ten 
days;  in  the  mildest  cases  it  may  not  be  more  than  five  days. 
The  submaxillary  glands  are  often  involved  in  connection  with  the 
parotids,  and  sometimes  also  the  sublingual,  although,  from  their 


262  PAKOTIDITIS. 

small  size  and  concealed  position,  their  tumefaction  escapes  notice. 
Rarely  the  tonsils  are  also  tumefied.  Sometimes  free  perspiration 
occurs  at  the  commencement  of  convalescence. 

The  swelling  of  the  parotids  sometimes  abates  suddenly,  and  in 
the  male  the  testicle,  epididymis,  and  tunica  vaginalis  become 
inflamed  ;  while  in  the  female,  the  mammary  glands,  ovaries,  or 
the  labia  majora,  are  the  seat  of  the  so-called  metastasis.  Occa- 
sionally these  inflammations,  which  are  less  frequent  in  young 
children  than  those  near  the  age  of  puberty,  when  the  sexual 
organs  are  becoming  more  developed,  occur  without  sjuibsidence  of 
the  parotid  swelling.  They  cause  considerable  increase  in  the 
fever  and  constitutional  disturbance,  but  with  proper  treatment 
decline  in  six  to  eight  days,  pursuing  the  same  course  as  the  parotid 
inflammation. 

Nature. — Parotiditis  is  contagious.  It  is  rare  in  infancy  and 
after  the  middle  period  of  life,  occurring  chiefly  in  childhood, 
youth,  and  early  manhood.  An  incubative  period  of  about  twelve 
days  was  ascertained  by  me  in  cases  occurring  in  the  Protestant 
Episcopal  Orphan  Asylum  of  this  city.  The  observations  of  others 
give  a  similar  result.  Parotiditis  is  a  blood  disease,  having  the 
local  manifestation  described  above,  and  which  is  our  only  means 
of  diagnosis. 

Diagnosis. — If  the  physician  has  seen  but  few  cases  of  mumps, 
there  is  danger  that  he  may  mistake  the  swelling  for  an  inflamed 
cervical  gland,  or  vice  versa^  but  an  inflamed  cervical  gland  presents 
to  the  finger  a  hardness  almost  like  that  of  cartilage,  and  it  is  cir- 
cumscribed or  round,  and  does  not  invest  the  ear.  These  charac- 
teristics contrast  with  the  elasticity,  seat,  and  shape  of  the  parotid 
swelling,  which  extends  forward  on  the  cheek,  and  surrounds  and 
elevates  the  lobule  of  the  ear.  Tumefaction  resulting  from  diph- 
theritic or  any  other  form  of  faucial  inflammation,  or  from  peri- 
ostitis affecting  the  root  of  the  posterior  molar,  may  be  detected  by 
examinino;  the  fauces  and  interior  of  the  mouth. 

Treatment. — This  is  very  simple.  Oakum  or  carded  wool  may 
be  bound  over  the  swelling,  and  the  surface  occasionally  rubbed 
with  sweet  oil.  Mild  laxative,  and  diaphoretic  drinks,  such  as 
bitartrate  of  potash  or  lemonade,  are  useful.  If  metastasis  occur, 
the  new  local  affection  should  receive  chief  attention.  It  should 
be  treated  in  the  same  manner  as  if  it  occurred  independently  of 
the  mumps.  The  employment  of  irritants  over  the  parotid  in  order 
to  cause  a  return  of  the  inflammation  from  the  sexual  organ  to  this 
gland,  does  not  have  the  effect  desired,  and  is  injurious. 


sectio:n'  iy. 

OTHER  GENERAL  DISEASES. 


CHAPTER    I. 

INTERMITTENT  FEVER. 

Intermittent  fever  is  a  constitutional  disease,  due  to  a  specific 
cause  emanating  from  the  soil.  It  spares  no  age.  Even  infants 
of  a  few  months  are  not  exempt  from  it,  and  it  is  said  that  a  preg- 
nant woman  affected  with  it  occasionally  observes  a  periodical 
tremor  of  the  foetus.  Stokes,  of  Dublin,  recorded  such  a  case;  and, 
according  to  Bouchut,  cases  have  been  observed  in  which  new-born 
infants,  whose  mothers  were  affected,  had  not  only  the  characteristic 
paroxysms,  but  also  enlarged  spleens,  showing  that  intra-uterine 
life  is  not  always  shielded  from  the  influence  of  the  specific  cause. 

It  is  not  fully  ascertained  whether  a  nursing  infant  may  contract 
intermittent  fever  by  lactation,  but  if  it  is  admitted  that  it  is  some- 
times communicated  to  the  foetus  through  the  maternal  circulation, 
it  does  not  seem  improbable  that  the  specific  principle  occasionally 
enters  the  milk  as  well  as  other  secretions.  I  have  frequently 
remarked  the  presence  of  the  disease  in  nursing  infants  whose 
mothers  were  affected,  and  in  one  instance  an  infant  at  the  breast, 
whose  mother  had  the  ague,  having  contracted  it  in  a  suburban 
village,  but  was  since  living  in  a  non-malarious  part  of  the  city, 
presented  evident  symptoms  of  the  disease.  Similar  observations 
by  Frank,  Burdel,  and  others,  do  not  indeed  fully  prove  the  com- 
municability  of  intermittent  fever  by  lactation,  but  render  it  highly 
probable. 

'No  ascertained  facts  relating  to  intermittent  fever  in  children 

CD 

throw  any  light  upon  the  ;*emarkable  and  much  discussed  observa- 
tions and  experiments  of  Prof.  Salisbury,  relating  to  the  etiology  of 
intermittent  fever.  Certainly,  if  the  cause  is  a  vegetable  cell  enter- 
ing the  blood  through  respiration,  it  sometimes  adheres  to  it  most 


26-i  INTEKMITTENT    FEVER. 

tenaciously,  and  is  probably  reproduced  in  it,  even  under  circum- 
stances favorable  for  its  elimination.  Thus,  at  one  of  my  cliniques 
at  Bellevue  Hospital  Medical  College  in  1871,  a  child  ten  years  old 
was  presented,  who  had  had  every  year  for  seven  years  attacks  of 
intermittent  fever.  The  disease  was  contracted  at  the  asre  of  three 
years  in  Harlem,  and  the  subsequent  residence  of  the  family  had 
been  in  a  part  of  the  city  where  there  was  no  malaria. 

Symptoms. — In  infancy,  and  especially  prior  to  the  age  of  eighteen 
months,  the  symptoms  differ  in  certain  respects  from  those  which 
characterize  the  disease  in  the  adult,  and  are  universally  known. 
In  childhood  the  symptoms  are  similar  to  those  in  the  adult,  and 
need  not,  therefore,  be  described  in  this  connection. 

In  the  nursing  infant  the  type  is  ordinarily  quotidian,  but  now 
and  then  tertian.  Advancing  beyond  the  age  of  eighteen  months, 
we  meet  more  and  more  cases  of  the  tertian  type,  and  in  childhood 
it  is  the  common  form.  I  have  known  the  quotidian  in  the  infant, 
when  cured,  to  reappear  a  few  weeks  after  as  a  tertian,  but  ordi- 
narily it  remains  quotidian  unless  the  patient  has  reached  the  age 
at  which  the  tertian  type  predominates. 

The  paroxysm  in  the  young  infant  presents  three  stages,  as  in  the 
adult,  but  while  the  second,  or  febrile,  is  well  marked,  the  first  and 
third  are  much  less  pronounced.  The  patient  does  not  shake  (ex- 
ceptionally one  does  even  within  the  first  year)  in  the  first  stage, 
but  a  slight  tremor  may  or  may  not  be  observed.  The  countenance 
presents  a  sunken  appearance;  the  lips  and  fingere  are  livid,  while 
portions  of  the  surface  not  livid  are  pallid,  with  the  goose-flesh  ap- 
pearance, which  is,  however,  less  marked  than  in  children  of  a  more 
advanced  age.  The  blood  leaves  the  surface,  which  consequently 
shrinks,  while  it  accumulates  in  the  veins  and  internal  organs  ;  the 
pulse  is  feeble,  and  readily  compressed ;  the  surface  grows  cool  from 
the  diminished  supply  of  blood,  but  the  breath  is  warm,  and  the 
internal  temperature,  so  far  from  being  reduced,  is  elevated  two  or 
three  degrees.  The  parents  may  be  alarmed  at  the  sudden  sinking 
of  the  vital  powers,  and  seek  medical  advice,  but  in  other  instances 
the  first  stage  is  so  slight  that  it  passes  unperceived  till  they  have 
been  taught  to  watch  for  it,  and  the  second  stage  first  attracts 
attention. 

In  the  second  or  febrile  stage,  which  immediately  succeeds,  the 
pulse  becomes  full  and  rapid,  120  to  130  or  140  beats  per  minute, 
and  the  external  as  well  as  internal  temperature  is  elevated  as  in 
few  other  diseases  (104°-108°).  The  face  is  flushed,  surface  dry,  and 
head  painful,  as  evinced  by  the  features.   This  stage  lasts  about  two 


SYMPTOMS.  265 

hours  or  somewhat  longer.  The  third  stage,  or  that  of  perspiration, 
succeeds,  which  terminates  the  suffering  of  the  patient  till  the  fol- 
lowing paroxysm.  In  infancy  the  perspiration  is  not  abundant,  and 
in  the  first  half  of  this  period  is  nearly  absent.  In  the  interval  of 
the  paroxysms  the  patient  appears  well,  except  a  degree  of  languor. 

During  the  cold  stage,  passive  congestion  of  the  internal  organs 
occurs  to  a  greater  or  less  extent,  but  the  circulation  is  equalized 
during  the  reaction  of  the  second  stage.  The  spleen,  whose  cap- 
sule is  distensible,  soon  enlarges  in  many  patients,  in  consequence, 
probably,  of  the  frequent  congestions,  constituting  the  "  ague  cake." 
This  enlargement  is  more  common  in  children  than  adults.  Since 
my  attention  has  been  particularly  directed  to  this  subject,  I  have 
been  able  to  feel  the  enlarged  spleen,  by  examination  through  the 
abdominal  walls,  in  about  half  of  the  cases  under  the  age  of  ten 
years.  The  organ  returns  to  the  normal  size  after  the  ague  is  cured. 
From  the  intimate  relation  of  the  spleen  to  the  composition  of  the 
blood,  it  is  evident  that  the  character  of  this  fluid  must  be  aflfected 
if  intermittent  fever  be  protracted.  The  blood  becomes  more  and 
more  impoverished,  and  a  state  of  decided  hydremia  supervenes. 
A  few  weeks'  continuance  of  the  ague  suflaces  to  produce  decided 
pallor  of  the  features,  and  surface  generally,  and  as  all  watery  blood 
is  prone  to  transudation,  such  patients  not  infrequently  present 
more  or  less  oedema  of  the  face,  ankles,  and  other  parts.  Some- 
times, also,  especially  under  unfavorable  hygienic  circumstances, 
purpuric  spots  (purpura  hremorrhagica)  appear  under  the  skin, 
affording  additional  proof  of  the  change  which  the  blood  has  un- 
dergone. 

Intermittent  fever  in  children,  if  proper  remedial  measures  are 
employed  at  an  early  period,  is  ordinarily  not  dangerous,  and  is 
quite  amenable  to  treatment;  but  that  comparatively  infrequent 
and  fatal  form  of  it,  designated  the  pernicious,  occurs  more  fre- 
quently in  children  than  adults.  In  Kew  York  city,  where  the 
type  of  malarial  diseases  is  mild,  I  have  never  met  a  case  of  perni- 
cious intermittent  in  the  adult,  but  I  can  recall  to  mind  such  cases 
in  children,  two  of  them  fatal.  This  form  of  the  fever  occurs  in  a 
smaller  proportionate  number  of  cases  in  infancy  than  in  child- 
hood, probably  because  the  cold  stage  is  less  pronounced.  In  the 
pernicious  ague,  the  system  is  overpowered — it  does  not  react  in  a 
degree  commensurate  with  the  intensity  of  the  disease.  The  patient 
enters  the  paroxysm,  becomes  stujDid,  and,  if  not  relieved  by  prompt 
and  efficient  measures,  enters  into  a  fatal  coma.  A  type  of  the  dis- 
ease, therefore,  which  would  not  be  pernicious  in  a  robust  individual. 


266  INTERMITTENT    FEVER. 

may  be  such  in  one  of  a  broken-down  constitution  and  feeble  reac- 
tive power.  In  most  cases  occurring  in  children  the  coma  is  pre- 
ceded by  eclampsia,  which  is  apt  to  be  general  and  protracted.  A 
nice  discrimination  would  no  doubt  exclude  from  the  list  of  the 
pernicious  aifection  certain  of  those  cases  in  which  coma  succeeded 
clonic  convulsions,  for  convulsions  occurring  from  other  causes  fre- 
quently end  in  coma,  and  in  all  probability  eclampsia  complicating 
intermittent  fever  has,  in  many  instances,  additional  and  distinct 
causes  quite  as  potent  as  the  malarial  poison  or  state.  But  practi- 
cally this  discrimination  would  subserve  no  useful  purpose.  It  is 
better  to  consider  as  pernicious  all  those  cases  in  which  alarming 
prostration  and  stupor  supervene  in  the  paroxysm,  requiring  ener- 
getic measures  to  produce  reaction  and  consciousness,  whether  con- 
vulsions have  occurred  or  not. 

Protracted  intermittent  fever  in  the  adult  occasionally  produces 
waxy  degeneration  of  organs,  and  also  a  greater  or  less  amount  of 
pigmentary  matter  in  the  blood  (melansemia).  In  children  both 
these  results  are  more  rare. 

Treatment. — The  same  mode  of  treatment  is  required  for  chil- 
dren as  for  adults,  namely,  the  employment  of  the  alkaline  prin- 
ciples of  cinchona.  The  sulphates  of  quinia  and  cinchonia  are 
most  frequently  prescribed.  From  observations  made  in  the  class 
of  children's  diseases  in  the  out-door  department  at  Bellevue,  two 
grains  of  the  sulphate  of  quinia  seem  to  have  about  the  effect  of 
three  grains  of  the  sulphate  of  cinchonia  in  the  treatment  of  ague. 
They  may  be  given  in  the  same  manner,  both  requiring  an  acid  for 
solution,  but  it  is  impossible  to  disguise  their  intense  bitterness. 
The  vehicle  which  I  prefer  for  their  administration  is  the  syrup 
of  raspberry,  which,  though  not  officinal,  is  easily  obtained.  The 
following  formula  is  for  a  child  of  three  years: — 

R.   Qui.  sulphat.  gr.  xij. 

Acid,  sulpliur.  dilut.  gtt.  xviij. 
Syr.  rubi.  idoei  §jss.    Miscc. 

One  teaspoonful  three  times  daily.  The  first  dose  should  be  ad- 
ministered immediately  after  the  fever  abates.  In  this  climate 
two  or  three  days  suffice  to  cure  the  disease,  after  which  one  dose 
daily  should  be  administered  for  a  week,  and  then  every  second  day 
for  two  or  three  weeks  longer. 

If  any  difliculty  is  experienced  in  administering  the  medicine 
on  account  of  its  bitterness,  the  dragees  may  be  employed,  if  the 
child  is  old  enough  to  swallow  them,  or  the  tannate  of  quinine. 


REMITTENT    FEVER.  267 

The  tannate  may  bo  adniinisterccl  by  substituting  tannic  acid  for 
the  sulpliuric.  One  grain  of  tannic  acid  is  sufficient  to  form  a 
tannate  with  four  grains  of  the  sulphate  of  quinire.  The  tannate, 
liowever,  is  not  as  reliable  as  the  sulphate,  and  it  is  necessary  to 
administer  it  in  a  somewhat  larger  dose. 


CHAPTER   II. 

EEMITTENT  FEVEE. 

If  a  physician  were  to  consult  the  standard  treatises  on  diseases 
of  children  in  order  to  ascertain  the  nature  of  remittent  fever,  he 
would  rise  from  the  perusal  with  no  clear  idea  of  it.  One  tells  us 
that  the  remittent  fever  of  children  is  identical  with  typhoid  fever 
of  adults;  another,  that  it  is  a  gastro-intestinal  inflammation;  and, 
finally,  Hillier  believes  that  there  is  properly  no  such  disease,  and 
that  the  term  should  be  dropped  from  the  nosology  of  children. 
There  is,  however,  a  remittent  fever  of  children  as  well  as  adults, 
and  much  of  the  confusion  wdiich  exists  in  reference  to  it  arises 
from  the  fact  that  writers  have  not  kept  in  view  what  constitutes  a 
fever. 

Febrile  action  which  has  a  local  cause  is  not  an  essential  fever, 
and  should  not  be  described  as  such.  It  happens  that  in  children 
a  symptomatic  remittent  fever  arises  from  a  variety  of  local  causes, 
as  dentition,  intestinal  worms,  subacute  gastro-intestinal  inflam- 
mation, etc.  But  all  such  cases  should  be  excluded  from  our  con- 
sideration of  remittent  fever,  as  clearly  as  we  distinguish  the  con- 
tinued fever  of  pneumonia  or  bronchitis  from  that  of  typhus  or 
typhoid. 

There  is  an  essential  remittent  fever  of  children  due  to  malaria. 
The  same  conditions  which  produce  intermittent  fever,  do,  in  a 
certain  proportion  of  cases,  produce  a  fever  which  does  not  in- 
termit, but  continues  with  more  or  less  pronounced  exacerbations 
a  certain  number  of  days,  when  it  ceases  or  becomes  intermittent. 
Cases,  too,  are  not  infrequent  in  localities  not  malarious,  of  a  remit- 
tent fever,  occurring  more  frequently  in  the  spring  and  autumn 
than  in  other  seasons.  Some  of  these  cases  are  perhaps  a  mild  type 
of  typhus,  but  in  most  instances  the  conditions  do  not  appear  to  be 
present  which  ordinarily  give  rise  to  typhus,  and  they  do  not  occur 


268  REMITTENT    FEVER. 

m  connection  with  cases  of  typhus  in  adults.     The  cause,  though 
obscure^  is  apparently  atmospheric. 

The  SYMPTOMS  of  remittent  fever  vary  in  different  cases.  The 
exacerbations  and  remissions  are  more  pronounced  in  some  than 
others.  Even  in  those  cases  in  which  the  fever  is  due  to  paludal 
emanations,  and  occurs  in  connection  with  cases  of  the  intermittent, 
the  febrile  movement  may  be  almost  uniform,  slight  exacerbations 
occurring  in  the  latter  part  of  the  day.  In  other  cases  the  exacer- 
bations and  remissions  are  pronounced,  the  febrile  excitement 
abating  in  a  perspiration.  Occasionally  the  fever  is  higher  on  each 
second  day.  Cephalalgia  is  common,  and  in  severe  cases  delirium 
and  stupor  are  not  infrequent.  There  may  be  distinct  remissions  in 
the  beginning,  and  afterwards,  for  a  few  days,  the  fever  be  pretty 
uniform,  when  it  again  remits  or  ceases.  The  tongue  is  covered 
with  a  light  fur.  Thirst,  loss  of  appetite,  a  tendency  to  constipa- 
tion, scanty  and  high-colored  urine,  containing  perhaps  urates,  and 
a  cough  due  to  mild  bronchitis,  are  common  symptoms. 

When  remittent  fever  is  due  to  marsh  emanations,  the  same  ana- 
tomical characters  are  doubtless  present  as  in  the  adult,  namely, 
blood  containing  more  or  less  pigmentary  matter,  enlargement  of 
the  spleen,  bronzing  of  the  spleen,  and,  in  severe  cases,  of  the  liver, 
and  sometimes  of  the  brain. 

The  DIAGNOSIS  is  not  always  easy.  On  the  one  hand,  local  diseases 
with  symptomatic  remittent  fever  are  to  be  excluded,  and,  on  the 
other,  typhus  and  typhoid.  The  discrimination  of  it  from  typhus 
and  typhoid  fevers  is  practically  of  little  moment,  but  it  is  a  mat- 
ter of  vital  importance  to  make  a  differential  diagnosis  between  it 
and  the  local  diseases.  I  have  known  one  of  the  acutest  dias^nos- 
ticians  and  most  eminent  physicians  of  'New  York  mistake  incipi- 
ent meningitis  for  it,  a  mistake  indeed  not  uncommon.  The  points 
involved  in  a  differential  diagnosis  will  be  considered  in  our  descrip- 
tions of  the  local  diseases. 

Treatment. — If  we  have  ascertained  by  a  careful  examination 
that  the  fever  is  remittent,  and  not  symptomatic  but  essential,  there 
is  one  remedy  which  is  required  in  nearly  all  cases,  namely,  quinia, 
or  its  equivalent,  cinchonia.  Mild  febrifuge  medicines,with  light 
diet,  may  be  first  employed  in  sthenic  cases,  in  which  the  pulse  is 
full  and  strong,  and  the  quinia  given  when  the  fever  has  somewhat 
abated.  The  diet  should  be  bland  but  nutritious,  and  the  bowels 
be  kept  regularly  open  by  citrate  of  magnesia  or  other  mild  ape- 
rient.    Bromide  of  potassium  or  hydrate  of  chloral  may  be  occa- 


TYPHOID    FEVER.  269 

sionnlly  employed  as  recommended  in  the  treatment  of  typlioid 
fever,  to  produce  quietude  or  sleep,  in  cases  attended  by  delirium 
or  insomnia.  A  warm  mustard  foot-bath,  and  cool  applications  to 
tlie  head,  are  useful  in  such  cases. 


CHAPTER    III. 

TYPHOID  FEVER. 


Typhus  and  ty]3hoid  fevers  occur  in  children,  but  the  former  is 
mild  and  infrequent,  rarely  occurring  except  when  adults  of  the 
same  household  are  affected.  It  requires  little  treatment,  except 
good  nursing.  Typhoid  fever,  on  the  other  hand,  is  not  infrequent 
in  children,  and,  as  it  presents  certain  peculiarities  prior  to  the  age 
of  puberty,  it  is  proper  to  describe  it  in  this  connection.  This  dis- 
ease is  much  less  frequent  in  infancy  than  in  childhood,  and  in  the 
first  half  of  infancy  is  believed  to  be  rare.  Still,  there  can  be  no 
doubt  that  many  cases  in  the  first  years  of  life  are  not  diagnosticated, 
being  mistaken  for  subacute  and  protracted  entero-colitis.  It  may, 
therefore,  be  more  common  in  the  infant  than  is  commonly  sup- 
posed. Its  period  of  greatest  frequency  in  children  is  between  the 
ages  of  six  and  twelve  years. 

Causes. — It  is  now  generally  admitted  that  typhoid  fever  is 
mildly  contagious,  and  that  its  specific  principle  abounds  largely 
in  the  dejections  and  excretions  of  the  patient.  It  is  uncertain 
whether  it  is  communicable  by  the  breath  of  the  patient,  or  exha- 
lations from  his  surface.  If  it  is,  it  is  slightly  so,  while  numerous 
observations  demonstrate  its  communicability  through  the  use  of 
night-stools  or  privies  which  contain  the  evacuations.  There  is 
little  doiibt  also  that  typhoid  fever  originates  de  7iovo,  caused  by  the 
miasm  produced  by  decaying  animal  or  vegetable  matter.  Nume- 
rous cases  have  been  observed  in  which  it  originated  from  defective 
sewerage,  or  decaying  vegetables  in  cellars,  in  localities  in  which  no 
case  had  previously  been  observed.  The  germs  of  the  disease  may 
not  only  be  received  into  the  system  by  inspiration,  but  also  through 
the  stomach,  for  the  use  of  well-water  which  contains  the  drainage 
of  sewers  has  repeatedly  been  known  to  cause  it.  Boys  are  more 
frequently  attacked  than  girls,  according  to  some  statistics  in  the 
proportion  of  three  to  one.     Deterioration  of  the  health  from  gene- 


270  TYPHOID    FEVER. 

ral  causes  increases  tlie  liability  to  be  attacked.  On  the  other  hand, 
those  having  tuberculosis,  carcinoma,  heart  disease,  and  probably 
certain  other  visceral  lesions,  are  more  apt  to  escape  than  those  in 
health. 

Anatomical  Charactees. — As  typhoid  fever  is  a  constitutional 
disease,  we  would  expect  to  find  earl}^  and  important  changes  in 
the  blood,  l^o  alteration,  however,  has  been  discovered  in  this 
fluid  peculiar  to  typhoid  fever.  The  amount  of  fibrin  is  diminished 
as  in  most  of  the  essential  fevers,  and  its.  coagulation  is  feeble, 
forming,  when  the  blood  stands,  soft,  small  and  dark  clots.  When 
the  fever  has  continued  for  some  time,  a  state  of  antemia  more  or 
less  decided  supervenes,  in  which  the  amount  of  albumen  and  blood 
corpuscles  is  diminished.  Although  there  are  often  decided  symp- 
toms referable  to  the  nervous  system,  no  constant  changes  have 
been  discovered  in  the  brain  or  spinal  cord.  The  changes  observed 
in  them  when  death  has  occurred  in  the  course  of  typhoid  fever 
have  been  for  the  most  part  due  to  other  causes.  It  is  different 
with  the  respiratory  system.  After  the  first  week  of  typhoid  fever 
bronchitis  is  almost  as  constant  as  inflammation  of  the  fauces  in 
scarlet  fever,  and  accordingly  we  find  in  fatal  cases  redness  and 
thickening  of  the  bronchial  mucous  membrane,  which  is  covered 
with  a  viscid  and  ordinarily  scanty  secretion.  Hypostatic  con- 
gestion of  the  lungs,  with  more  or  less  oedema,  and  in  severe  and 
enfeebled  cases  hypostatic  pneumonia,  are  not  uncommon.  In  the 
bronchitis  and  state  of  feebleness  we  have  the  causes  of  pulmonary 
collapse,  and  this  lesion  is  not  infrequent  over  limited  portions  of 
the  lungs,  especially  if  the  bronchitis  is  unusually  severe. 

The  lesions  occurring  in  the  digestive  system  are  important. 
The  mucous  membrane  of  the  small  intestine  is  more  or  less  in- 
jected, and  at  an  early  period,  even  by  the  second  or  third  day,  the 
patches  of  Peyer,  solitary  glands,  and  at  the  same  time  the  mesen- 
teric, begin  to  enlarge.  It  has  been  stated  by  high  authorities  that 
the  enlargement  is  due  to  infiltration  with  a  peculiar  substance, 
which  has  been  termed  the  typhous  material.  I  have  made  micro- 
scopic examination  of  these  glands  in  typhoid  fever  of  the  adult, 
and  have  found  a  notable  increase  of  the  small  round  granular 
cells  of  which  these  glands  are  composed.  I  do  not,  therefore, 
doubt  that  the  enlargement  is  due  mainly  to  hyperplasia  of  the 
cellular  elements  of  the  glands,  though  there  is  probably  infiltra- 
tion to  a  certain  extent  of  inflammatory  products  between  the  cells. 
The  mucous  membrane  over  the  glands  undergoes  inflammatory 
thickening  and  softening.     In  the  adult,  sloughing  of  this  mem- 


SYMPTOMS.  271 

brane  is  frequent,  witli  the  disintegration  of  the  glands  and  their 
elimination  into  the  intestines,  producing  ulcers,  small  and  circular, 
corresponding  with  the  site  of  the  solitary  glands,  large  and  oval 
or  irregular,  corresponding  with  the  site  of  the  agminate.  Disin- 
tegration of  these  glands  and  the  formation  of  ulcers  are  less  fre- 
quent in  children  than  adults.  In  the  adult,  who  recovers,  the 
mesenteric  glands,  and  those  of  the  solitary  and  agminate  which 
are  not  destroyed,  return  to  their  normal  state  by  fatty  degene- 
ration, liquefaction  and  absorption  of  the  redundant  cells.  In  the 
child  this  is  the  common  result,  instead  of  sloughing  and  disinte- 
gration, as  regards  both  the  solitary  and  agminate  glands,  and 
uniform  result  as  regards  the  mesenteric,  and  I  may  add  bronchial 
glands,  which  are  also  in  a  state  of  hyperplasia.  The  absence  of 
ulceration  or  its  slight  extent  affords  explanation  of  the  fact  that 
intestinal  perforation  is  very  rare  in  children. 

The  spleen  gradually  enlarges,  often  to  twice  the  normal  size,  has 
a  dark  red  color,  and  is  softened.  Enlargement  of  the  spleen  pos- 
sesses o-reat  diae-nostic  vakie  in  those  cases  in  which  the  diaguosis 
is  obscure.  For  while  very  similar  intestinal  lesions  may  occur 
in  chronic  entero-colitis,  the  coexistence  of  these  lesions  with  the 
splenic  enlargement  and  softening  shows  the  constitutional  nature 
of  the  afi'ection. 

In  cases  which  are  severe,  and  presenting  a  decidedly  adynamic 
type,  the  muscles  become  soft  and  flabby,  and  the  action  of  the 
heart  is  feeble,  more  or  less  passive  congestion  of  the  viscera  is  the 
result.  In  such  cases  congestion  of  the  kidneys  and  albuminuria  are 
not  infrequent. 

Symptoms. — Typhoid  fever  has  a  prodromic  stage  of  a  few  days, 
sometimes  of  a  week  or  more,  in  which  the  child  appears  languid, 
indisposed  to  play,  and  has  little  appetite,  but  complains  of  no  pain 
unless  occasional  slight  headache,  and  has  no  symptom  which  would 
lead  the  friends  or  even  physicians  to  suspect  the  grave  nature  of 
the  disease  which  impended.     By  and  by  a  slight  fever  occurs. 

The  febrile  movement,  which  gradually  becomes  more  pro- 
nounced, remits,  but  does  not  cease  in  the  morning,  and  has  even- 
ing exacerbations.  After  the  first  week  of  fever  the  remissions  are 
less  marked,  but  the  fever  is  not  uniform  at  any  period  in  its  course. ' 
Hence  some  of  our  ablest  writers  on  diseases  of  children  continue 
to  designate  typhoid  fever  of  children  remittent  fever,  fully  aware 
of  its  identity  with  typhoid  fever  of  the  adult.  As  the  case  advances, 
the  appetite  fails,  all  solid  food  being  refused,  and  liquid  food  being 
taken  more  from  thirst  than  hunger.     The  tongue  in  the  first  week 


272  TYPHOID    FEVER. 

is  covered  with  a  light  moist  fur,  and  in  some  patients  throughout 
the  course  of  the  disease,  but  in  others  having  a  graver  type  of  the 
fever  the  tongue  after  the  first  week  is  dry  and  brown.  During 
the  prodromic  period,  and  in  the  first  week,  the  bowels  act  regu- 
larly, or  are  slightly  relaxed,  and  they  are  readily  afiected  by  pur- 
gative medicines.  After  the  first  week  there  is  in  most  children  a 
tendency  to  diarrhoea,  which  requires  now  and  then  the  use  of 
astringents,  the  stools  being  watery  and  brown,  or  dark  yellow. 
The  abdominal  walls  are  seldom  retracted,  but  prominent,  especially 
after  the  first  week,  in  consequence  of  meteorism  which  is  present 
in  children  as  well  as  adults.  Sometimes  there  is  apparent  tender- 
ness, when  pressure  is  made  over  the  right  iliac  region,  but  this 
must  not  be  confounded  with  hyperfesthesia,  which  is  common  in 
the  commencement  of  febrile  diseases  in  children,  and  which  is 
observed  especially  upon  the  abdomen,  chest,  and  inner  part  of  the 
thighs. 

The  respiration  in  the  first  week  is  slightly  accelerated,  as  it  is 
in  all  febrile  diseases.  In  the  second  week,  and  subsequently  when 
bronchitis  is  developed,  the  respiration  is  ordinarily  more  accele- 
rated, though  not  in  a  marked  degree,  unless  in  those  exceptional 
instances  in  which  there  is  an  abundant  collection  of  mucus  in  the 
smaller  bronchial  tubes.  A  cough  is  always  present,  dependent  on 
the  bronchitis,  and  varying  in  character  according  to  the  degree 
and  stage  of  the  inflammation.  In  the  first  days  of  the  fever  it  is 
infrequent,  and  hacking  ;  at  a  later  stage  it  is  more  frequent,  and 
not  so  dry,  though  in  cases  of  ordinary  severity  the  amount  of  ex- 
pectoration is  inconsiderable.  Hypostatic  congestion,  oedema,  hypo- 
static pneumonia,  splenization,  or  thickening  of  the  alveolar  walls, 
and  collapse,  which  may  and  some  of  which  not  infrequently  do 
occur  in  the  advanced  disease,  increase  more  or  less  the  frequency 
of  the  respiration  and  the  cough,  and  modify  the  physical  signs. 

The  pulse  in  the  first  week,  in  ordinary  cases,  is  from  100  to 
110  or  115.  It  gradually  becomes  more  accelerated,  numbering  in 
the  second  week  120  or  more;  in  grave  cases  even  160.  The  more 
frequent  the  pulse,  the  greater  the  danger  and  more  unfavorable 
the  prognosis.  During  the  exacerbations  the  number  of  pulsations 
per  minute  is  15  or  20  more  than  in  the  remissions.  The  change 
in  temperature  corresponds  with  that  of  the  pulse,  being  from  1° 
to  2°  higher  in  the  exacerbation  than  remission.  The  extremes  of 
temperature  in  cases  of  ordinary  severity  are  about  101°  and  104°. 
A  temperature  above  105°  shows  a  grave,  probably  a  malignant, 
type  of  the  disease,  or  else  a  serious  complication. 


COMPLICATIONS.  273 

Tlicrc  is  great  variation  as  regards  the  symptoms  referable  to  the 
nervous  system.  Headache  is  common  in  the  prodromic  and  initial 
stages,  after  which  it  ceases.  A  few  arc  delirious  even  from  an 
early  period,  screaming  loudly,  or  muttering  incoherently,  but  the 
majority  are  quiet,  having,  indeed,  a  degree  of  mental  dulness,  but 
being  able  to  appreciate  questions  when  aroused,  and  answering 
correctly.  Subsultus  tendinum  and  carphologia,  which  some  ex- 
hibit, show  that  there  is  profound  disturbance  of  the  nervous 
system.  Epistaxis  occurs  occasionally  in  the  first  week  as  in  the 
adult,  but  is  not  abundant. 

The  rose-colored  eruption  appears  in  children  as  well  as  adults 
between  the  sixth  and  twelfth  days,  but  is  more  frequently  absent 
in  the  former  than  latter,  sometimes  the  number  of  sj^ots  is  less 
than  half  a  dozen.  Sudamina  are  common  in  the  second  and  third 
weeks,  and  perspirations  may  occur  at  anj^  time  in  the  course  of 
the  fever,  but  without  amelioration  of  symptoms.  More  or  less 
deafness  is  common,  being  in  most  instances  a  purely  nervous 
symptom,  without,  therefore,  any  structural  change  in  the  ear,  but 
it  is  possible,  as  has  been  suggested  by  certain  writers,  that  it 
sometimes  results  from  inflammatory  thickening  of  the  Eustachian 
tube  or  external  meatus,  or  to  a  weakened  and  flabby  state  of  the 
muscles  of  the  ear. 

The  duration  of  typhoid  fever  is  not  uniform;  while  mild  cases 
may  end  in  two  weeks,  those  of  a  severer  type  continue  three  or 
even  four,  the  patient  becoming  progressively  more  emaciated  and 
feeble.  In  protracted  and  severe  cases  his  condition  seems  very 
unpromising  to  one  not  familiar  with  the  clinical  history  of  the 
fever.  Pale,  emaciated,  and  feeble,  probably  passing  his  evacua- 
tions in  bed,  taking  little  notice  of  objects  around  him,  he  presents, 
at  the  close  of  the  third  week,  an  appearance  of  helplessness,  not- 
withstanding the  best  of  nursing,  and  the  constant  employment  of 
sustaining  measures,  which  is  truly  discouraging. 

Complications. — The  chief  complications  of  typhoid  fever  are 
broncho-pneumonia,  already  sufficiently  described,  enteritis,  intes- 
tinal hemorrhage,  peritonitis,  otitis,  parotiditis,  and  muguet.  In 
one  instance  I  lost  a  patient  about  ten  years  old,  in  whom  the  fever 
had  nearly  terminated,  by  the  sudden  accession  of  croup.  There 
is,  as  we  have  seen,  in  ordinary  cases,  a  degree  of  inflammation  of 
the  mucous  membrane  of  the  air-passages,  and  of  the  intestines 
especially  in  the  vicinity  of  the  patches  of  Peyer.  It  is  easy  to 
understand  how,  under  circumstances  which  may  arise  in  the  fever 
favorable  to  the  development  of  mucous  inflammations,  the  bron- 
18 


274  TYPHOID    FEVER. 

cliitis  and  enteritis  may  so  increase  as  to  constitute  complications. 
They  are  the  most  frequent  of  the  serious  com^ilications. 

Intestinal  hemorrhage  is  an  occasional  complication.  Hillier 
met  four  cases  in  thirty  of  the  fever.  It  indicates  the  presence  of 
ulcers  upon  the  surface  of  the  intestines.  It  is  one  of  the  most 
serious  of  the  complications.  Some,  in  whom  it  has  occurred, 
recover,  but  others  die.  Otitis,  commencing  with  pain,  and  pro- 
ducing a  discharge  which  may  continue  for  weeks,  is  not  rare, 
though  less  frequent  than  in  scarlet  fever.  The  otitis  is  commonly 
external,  but  it  may,  in  scrofulous  subjects,  extend  to  the  middle 
ear. 

Intestinal  perforation  is  more  rare  in  children  than  in  adults,  as 
might  be  inferred  from  the  statement  already  made,  that  intestinal 
ulceration  is  less  frequent  and  extensive  in  them.  Statistics  show 
that  "perforation  occurs  only  once  in  232  cases.  Therefore,  as  per- 
foration is  the  common  cause  of  peritonitis  in  this  disease,  this 
inflammation  is  a  rare  complication.  Peritonitis  may,  however, 
occur  in  typhoid  fever  without  j^erforation.  In  one  such  case  (an 
adult)  in  the  fever  wards  attached  to  Charity  Hospital,  local  peri- 
tonitis with  fibrinous  exudation  occurred  opposite  two  ulcerated 
patches  of  Peyer,  the  ulcers  extending  nearly  to  the  peritoneum, 
])ut  not  perforating.  The  lesions  observed  in  this  case  throw  light 
on  those  cases  of  peritonitis  complicating  typhoid  fever  which 
recover,  the  cause  of  which  has  received  a  diiFerent  explanation. 

In  advanced  and  greatly  debilitated  cases,  thrush  sometimes 
appears  in  the  interior  of  the  mouth,  and  upon  the  fauces.  It  is 
always  an  unfavorable  prognostic  symptom  in  children  sufifering 
from  chronic  or  protracted  disease.  Parotiditis  is  also  a  rare  com- 
plication. 

Diagnosis. — This  is  more  difficult  in  children  than  in  adults,  and 
the  younger  the  child  the  greater  the  difficulty.  In  infants  pro- 
tracted entero-colitis,  with  febrile  action  and  dry  furred  tongue, 
cannot  in  certain  cases  be  positively  diagnosticated  from  typhoid 
fever  by  the  symptoms  and  clinical  history.  Typlioid  fever  is 
believed,  however,  to  be  rare  at  this  age.  When,  however,  as  now 
and  then  happens,  a  young  child  presents  the  symptoms  character- 
istic of  protracted  subacute  entero-colitis,  or  typhoid  fever,  and 
older  members  of  the  household  have  the  fever,  it  is  highly  probable 
that  the  case  is  one  of  the  latter  disease,  and  it  should  be  treated 
accordingly. 

Even  in  older  children  typhoid  fever  is  apt  to  be  mistaken  for 
simple  subacute  enteritis,  or  entero-colitis,  or  vice  versa.     The  fol- 


PROGNOSIS.  275 

lowing  facts  aid  in  the  dift'erential  diagnosis.  In  typhoid  fever 
there  is  total  loss  of  ai»petite,  while  in  the  suhacute  intestinal  inflam- 
mation food  is  not  entirely  refused.  Diarrhoea  commences  early 
in  the  inflammation,  while  in  the  fever  it  is  not  ordinarily  till  after 
the  lapse  of  a  few  days.  The  tenderness  of  the  fever  is  either  not 
appreciable,  or  it  is  located  in  the  right  iliac  region ;  in  the  other 
disease  it  is  general  over  the  abdomen,  or  located  in  the  umbilical 
region.  In  typhoid  fever  there  is  bronchitis  with  a  cough  which 
is  absent  in  the  inflammation.  In  typhoid  fever  there  are  certain 
other  symptoms,  more  or  fewer  of  which  are  present  in  most  cases, 
and  which  do  not  occur  in  the  intestinal  diseases,  except  as  a  coinci- 
dence. For  example,  headache,  epistaxis,  stupor,  delirium,  and 
perhaps  the  rose-colored  spots. 

T^^phoid  fever  may  be  mistaken  for  meningitis,  during  the  first 
week,  but  in  meningitis  there  is  more  constipation,  irritability  of 
stomach,  and  less  elevation  of  temperature;  moreover,  in  menin- 
gitis, at  a  comparatively  early  stage,  we  are  able  to  detect  patches 
of  congestion  of  the  features  coming  and  disappearing  suddenly; 
slight  inequality  of  the  pupils,  or  their  oscillation  when  the  light  is 
uniform ;  signs  which  are  lacking  in  tj'^phoid  fever.  In  a  doubtful 
case  the  ophthalmoscope  might  be  employed,  which  in  meningitis 
discloses  congestion  of  the  vessels  of  the  retina,  cedema,  etc.,  ana- 
tomical changes  which  do  not  pertain  to  typhoid  fever. 

The  differential  diagnosis  of  typhoid  fever  and  acute  tuberculosis 
may  be  made  by  attention  to  the  following  points.  In  tuberculosis 
there  is  cough,  with  some  acceleration  of  respiration  from  the  first, 
without  epistaxis,  stupor,  or  other  nervous  symptoms,  and  without 
the  abdominal  symptoms  which  are  so  prominent  in  the  fever. 

Duration. — The  duration  of  typhoid  fever  varies  from  two  to 
about  four  weeks,  and  complications  which  may  arise  greatly  retard 
convalescence.  Recovery  from  a  severe  and  protracted  attack  is 
slow,  several  weeks  or  even  months  elapsing  before  complete  resto- 
ration to  health.  A  tendency  to  diarrhoea  may  continue  several 
weeks  after  the  fever  proper  ceases,  necessitating  a  rigid  oversight 
of  the  diet,  and  the  occasional  employment  of  astringents. 

Prognosis. — A  much  larger  percentage  of  children  recover  than 
of  adults.  Although  there  is  great  emaciation  with  loss  of  strength, 
recovery  may  be  confidently  predicted,  provided  no  serious  compli- 
cation occurs.  In  the  fatal  cases  which  I  have  met,  the  unfavorable 
result  occurred  as  a  rule  from  the  complications,  rather  than  directly 
from  the  fever.  The  condition  in  which  severe  typhoid  fever  leaves 
a  patient  is  favorable  to  the  development  of  .tubercles,  and  now  and 


276  TYPHOID    FEVER. 

then  they  occur,  disappointing  our  expectations  and  prediction  of 
recovery. 

Treatment. — As  typhoid  fever  is  self-limited,  the  treatment  re- 
quired in  ordinary  cases  is  simple.  It  should  be  of  a  sustaining 
nature,  both  as  regards  diet  and  medicinal  agents,  and  any  untoward 
symptoms  should  be  promptly  met  by  appropriate  measures.  The 
food  should  be  in  the  liquid  form ;  solid  food  is,  indeed,  in  most 
cases,  refused.  Beef-tea,  milk,  rice  or  barley-water,  with  milk,  may 
be  allowed  from  the  first.  Mild  cases  require  no  stimulants,  still 
the  moderate  use  of  wine  is  not  contraindicated  in  such  cases,  and 
may  be  allowed  at  an  early  period.  In  grave  cases,  characterized 
by  a  dry  and  furred  tongue,  and  quick  and  compressible  pulse,  milk- 
punch  or  wine-whey  should  be  employed  in  suitable  quantity  at 
reo;ular  intervals. 

When  the  fever  is  mild  and  pursuing  its  normal  course,  a  simple 

febrifuge  may  be  employed,  as  spts.  setheris  nitrosi,  with  syrup  of 

ipecacuanha. 

5.  Spts.  aether,  nit.  gij ; 
Syr.  ipecac.  5iij  ; 
Syr.  simplic.  §jss.     Misce. 
Dose,  one  teaspoonful  every  three  liours  to  a  child  of  six  years. 

If  the  fever  has  distinct  evening  exacerbations,  quinine  is  indi- 
cated as  an  antiperiodic,  and  in  cases  of  an  asthenic  type,  it  may  be 
employed  in  smaller  doses  as  a  tonic.  In  either  of  these  conditions 
it  will  be  found  useful.  In  cases  attended  with  great  restlessness 
or  delirium,  an  appropriate  dose  of  bromide  of  potassium  or  hydrate 
of  chloral  at  night,  will  procure  rest,  and  be  followed  by  no  unfa- 
vorable result.  I  prefer  the  hydrate  of  chloral  given  in  a  small 
dose.  A  single  dose  of  two  or  three  grains  of  this  agent  will  gene- 
rally be  sufficient.  For  the  diarrhoea,  I  ordinarily  prescribe  pare- 
goric, with  half  its  quantity  of  the  fluid  extract  of  catechu  in  chalk 
mixture.  The  state  of  anaemia  which  is  present  in  the  advanced 
disease  and  in  convalescence  requires  the  employment  of  iron.  The 
citrate  of  iron  and  quinine  will,  under  such  circumstances,  be  found 
useful. 


ACUTE    RHEUMATISM.  277 


CIIArTER  IV. 

ACUTE  RHEUMATISM. 

Rheumatism  is  a  constitutional  disease  with  a  local  manifesta- 
tion, namely,  an  inflammation  of  the  sero-fibrous  tissues  chiefly  in 
and  around  the  articulations,  but  occasionally  in  other  parts.  It 
is  less  frequent  prior  to  puberty  than  in  the  years  succeeding  it ; 
still,  it  is  not  uncommon  in  children  after  the  fifth  year.  Under 
this  age  it  is  comparatively  rare,  but  is,  probably,  not  so  infrequent 
as  is  commonly  supposed.  For  while  in  the  adult  the  diagnosis  of 
rheumatism  is  easy,  in  children  this  disease  is  likely  to  be  over- 
looked, if,  as  is  true  in  a  large  proportion  of  cases  in  early  life,  the 
swelling  and  redness  of  the  affected  joints  are  slight,  and  only  a 
few  joints  are  inflamed.  If  there  is  cardiac  inflammation,  the 
articular  affection  may  be  nearly  absent,  thus  rendering  the  diag- 
nosis more  obscure.  That  rheumatism  is  not  so  very  rare  under 
the  age  of  five  years,  I  infer  from  the  fact  that  we  now  and  then 
meet  with  cases  of  valvular  disease  in  children  of  this  a^e  or  older, 
which,  there  can  be  little  doubt,  had  its  origin  in  rheumatism, 
although  the  parents  are  not  aware  that  there  has  ever  been  an  at- 
tack of  this  disease.  Several  such  cases  have  recently  been  brought 
to  the  children's  class  in  the  Out-door  Department  at  Bellevue. 
Thus,  in  January,  1871,  a  little  girl,  three  years  old,  was  presented, 
having  distinct  aortic  direct,  and  mitral  regurgitant  murmurs. 
The  mother  was  not  aware  that  she  had  had  rheumatism,  but  at 
the  age  of  twenty  months  she  had  for  several  days  pretty  active 
febrile  symptoms,  which  the  physician  attributed  to  disease  of  the 
lungs.  In  April,  1(S71,  another  girl,  of  the  same  age,  was  brought 
to  the  clinique,  having  a  distinct  mitral  regurgitant  murmur.  The 
mother  stated  that  she  had  been  well  till  a  month  previously, 
when  she  was  confined  to  her  bed  for  a  few  days,  having  a  high 
fever.  She  was  attended  by  a  homoeopathic  physician,  and  the 
exact  character  of  her  sickness  the  mother  was  not  able  to  state. 
Further  medical  advice  was  sought,  as  the  child  remained  delicate> 
thousch  her  health  was  better  than  at  first.  There  can  be  little 
doubt  that  the  obscure  fever  in  this  case  had  been  rheumatic.     In 


278  ACUTE    RHEUMATISM. 

another  child  treated  elsewhere,  not  old  enough  to  relate  the 
subjective  symptoms,  there  was,  in  addition  to  an  intense  fever, 
evident  pain  in  one  foot  or  leg,  when  the  limb  was  moved.  Still, 
the  nature  of  the  disease  was  not  diagnosticated  till  some  time 
after  recovery,  when  a  valvular  murmur  was  accidentally  discov- 
ered. Such  histories,  which  I  do  not  think  are  rare,  show,  if  my 
opinion  of  them  is  correct,  that  rheumatism  may  occur  not  very 
rarely  in  young  children,  even  infants,  for  which  purpose  they  are 
here  introduced,  but  they  inculcate  the  important  practical  lesson, 
that  the  disease  at  this  age  may  be  so  obscure,  or  latent,  as  to  be 
overlooked  even  by  good  diagnosticians. 

Some  observers,  meeting  cases  of  valvular  disease  in  children, 
without  the  history  of  rheumatism,  have  concluded  that  rheumatism 
is  not  the  chief  cause  of  endocarditis  at  this  age  (Dr.  A.  Steifen, 
Jahrhuch  fur  Kinder k.^  1870);  but  the  explanation  which  I  have 
given  seems  to  me  more  in  consonance  with  the  facts.  Scarlet 
fever  not  infrequently  causes  endocarditis,  but  this  exanthem  is 
not  apt  to  occur  without  detection,  and  it  has  been  as  often  absent 
as  has  rheumatism  from  the  histories  as  given  by  the  parents  of 
young  children  with  valvular  disease,  whom  I  have  examined. 
Moreover,  it  is  a  question  whether  the  endocarditis  of  scarlet  fever 
is  not,  properly  speaking,  of  a  rheumatic  origin. 

Rheumatism  in  children  is  primary  or  secondary.  The  secondary 
form  occurs  chiefly  in  the  declining  stage  of  scarlet  fever  and 
variola.  It  is  stated,  also,  to  occur  occasionally  in  new-born  infants 
during  epidemics  of  puerperal  fever.  I  have  not  observed  such 
cases. 

Causes. — The  important  cause  of  rheumatism  is  a  predisposition, 
which,  in  a  large  proportion  of  cases,  is  inherited.  Hence  the  fact 
that  it  is  apt  to  occur  in  different  members  of  the  same  family. 
When  the  family  history  shows  a  strong  predisposition  to  rheuma- 
tism, it  occurs  in  the  child  from  a  slight  exciting  cause;  if  no 
such  predisposition  exists,  it  only  occurs  through  unusual  circum- 
stances of  exposure.  The  ordinary  exciting  cause  is  the  same  as 
in  most  idiopathic  inflammations,  namely,  exposure  to  cold;  but  a 
strong  rheumatic  diathesis  appears  to  be  sufficient  in  itself  to  pro- 
duce an  outbreak  of  the  disease.  Children  who  have  had  one 
attack  are  especially  liable  to  another. 

Symptoms. — The  commencement  of  acute  idiopathic  rheumatism 
is  in  most  cases  sudden;  occasionally  fever,  and  a  degree  of  sour- 
ness or  stiffness,  precede  the  articular  affection  for  a  few  hours  or 
days.    The  inflammation,  slight  at  first,  increases  gradually,  attain- 


SYMPTOMS.  279 

ing  its  maximum  intensity  within  one  or  two  days.  The  joint  is 
painful,  red,  hot,  and  swollen.  The  swelling  is  due  to  inflamma- 
tory cedema  of  the  tissues  surrounding  the  joint  and  effusion 
within  the  joint.  As  in  all  inflammations,  the  vascularity  of  the 
parts  involved  is  increased,  the  synovial  membrane  loses  more  or 
less  its  lustre,  and  the  effused  fluid,  which  is  mainly  serum,  has 
been  found,  in  most  of  the  cases  in  which  an  opportunity  was  pre- 
sented to  examine  it,  to  contain,  like  the  pleuritic  exudation,  a 
few  globules  of  pus.  Rarely,  in  a  reduced  state  of  the  system,  so 
much  pus  is  produced  within  the  joint  as  to  constitute  a  true 
abscess,  and  rarely  also  fibrin  is  exuded,  producing  a  rubbing  sen- 
sation when  the  joint  is  moved,  and  endangering  permanent  adhe- 
sion of  the  articular  surfaces.  Fortunately,  however,  in  the  vast 
majority  of  cases,  the  substance  exuded  both  without  and  within  the 
joint  is  mainly  serum,  and  therefore  the  rapid  subsidence  of  the 
swelling  when  the  inflammation  ceases.  The  pain  is  commonly 
not  severe  when  the  child  is  quiet,  but  it  is  greatly  increased  if  the 
joint  is  pressed  or  the  limb  moved. 

The  joints  of  the  extremities  are  most  frequently  the  seat  of 
rheumatic  inflammation,  but  occasionally  those  of  the  trunk,  as 
the  intervertebral,  the  symphysis  pubis,  etc.,  are  involved.  As  the 
inflammation  abates  in  the  articulations  first  aft'ected  it  reappears 
in  others,  unless  the  materies  morbi  has  been  eliminated  from  the 
system.  It  is  seldom  that  more  than  two  or  three  of  the  joints  are 
in  a  state  of  active  inflammation  at  the  same  time. 

The  temperature  in  acute  rheumatism  is  elevated  two  or  three 
degrees  above  that  of  health,  and  the  pulse  varies  from  120  to  140, 
its  frequency  depending  on  the  age  of  the  patient,  as  well  as  the 
gravity  of  the  disease.  Perspiration  is  a  common  symptom.  The 
appetite  is  impaired,  the  tongue  slightly  coated,  and  the  bowels 
constipated.  The  watery  element  in  the  urine  is  diminished,  as  in 
most  febrile  diseases.  There  is  no  corresponding  reduction  in  the 
solid  elements,  so  that  the  urine  is  rendered  more  dense,  and  its 
specific  gravity  is  high.  The  amount  of  urea  and  coloring  matter 
excreted  from  the  kidneys  is  augmented  during  the  active  period 
of  rheumatism,  and  the  urine,  when  it  cools,  deposits  urates.  In 
ordinary  cases  there  is  no  prominent  symptom  referable  to  the 
nervous  system,  with  the  exception  of  the  pain  in  the  affected  joint. 

Acute  rheumatism,  if  only  the  articulations  were  involved, 
would  be  a  disease  of  little  danger,  however  painful,  but  unfortu- 
nately, in  its  proneness  to  produce  specific  inflammation  of  the 
sero-fibrous   tissues,  the  heart  frequently  becomes   involved,  less 


280  ACUTE    RHEUMATISM. 

frequently  the  lungs  and  pleura,  and  in  rare  instances  the  cerebra^ 
or  spinal  meninges.  Endocarditis  is  the  most  frequent  of  the  heart 
inflammations  occurring  in  rheumatism;  pericarditis,  though  less 
common,  is  not  infrequent,  while  in  rare  instances  myocarditis 
occurs,  usually  associated  with  the  other  inflammations.  Endo- 
carditis is  limited  to  the  left  side  of  the  heart,  and  seldom  continues 
long  without  engaging  the  valves,  aortic  or  mitral,  or  both,  causing 
their  infiltration,  fibroid  degeneration,  with  consequent  thickening, 
and  sometimes  adhesion.  The  valvular  lesion  thus  produced  is 
in  most  instances  permanent,  so  impairing  the  action  of  the  valves 
as  to  obstruct  in  greater  or  less  degree  the  flow  of  blood  through 
the  orifice  or  allow  its  regurgitation. 

The  mitral  valve  is  more  frequently  affected  than  the  aortic,  at 
least  bruits  produced  by  this  lesion  are  more  frequent  in  the  mitral 
than  aortic  orifice,  and  when  they  are  heard  in  both  orifices  they 
are  commonly  loudest  in  the  mitral.  This  fact,  noticed  by  difierent 
observers,  I  have  repeatedly  verified  by  observations  in  this  city. 

While  the  articular  aftection  pertains  to  the  clinical  history  of 
rheumatism,  the  internal  inflammation,  whether  of  the  heart,  lungs, 
pleura,  or  meninges,  though  similar  as  regards  its  pathological  cha- 
racter, is  properly  regarded  as  a  complication.  Acute  rheumatism 
is  so  frequently  complicated  by  one  or  the  other  of  these  afiections, 
that  any  disproportionate  severity  in  the  general  symptoms,  as 
compared  with  the  inflammation  of  the  joints,  or  any  sudden  and 
unexpected  increase  in  the  symptoms,  should  always  lead  the 
physician  to  examine  thoroughly  the  condition  of  those  organs 
which  are  most  frequently  affected. 

Inflammatory  complications  occur,  as  a  rule,  during  the  active 
period  of  rheumatism,  when  the  inflammation  is  passing  from 
joint  to  joint.  If  the  general  symptoms  begin  to  improve,  and  no 
new  joints  are  involved,  the  liability  to  complications  is  greatly 
diminished.  Secondary  rheumatism,  occurring  in  most  instances 
in  connection  with  certain  eruptive  fevers,  especially  scarlatina, 
commonh^  affects  only  a  few  joints,  often  only  one  or  two,  as  the 
wrist,  and,  though  painful,  is  attended  by  slight  swelling  and 
redness. 

Duration,  Prognosis. — "With  proper  treatment  and  without 
complication  the  febrile  action  in  a  few  days  begins  to  abate,  and 
the  disease  commonly  terminates  within  two  weeks.  Its  duration 
is  ordinarily  shorter  than  in  rheumatism  of  the  adult.  Fluctua- 
tions, however,  are  liable  to  occur.  The  disease  may  appear  to  be 
abating,  and  the  articular  inflammations  nearly  cease,  when  they 


DIAGNOSIS. 


281 


return  for  a  time,  often  without  new  exposure  and  witliout  appre- 
ciable cause.  The  prognosis,  even  when  cardiac  inflammation  has 
supervened,  is  in  most  cases  favorable,  except  so  far  as  the  lesion 
resulting  from  this  inflammation  is  concerned,  which  being  perma- 
nent may  entail  much  subsequent  suffering,  and  occasion  death 
after  months  or  years.  Indeed,  what  is  most  to  be  dreaded  in  cases 
of  acute  rheumatism  is  valvular  disease  or  pericardial  adhesion  with 
its  remoter  consequences,  namely,  hypertrophy  of  heart,  congestion 
and  oedema  of  the  lungs,  dropsies,  etc. 

Secondary  rheumatism  occurring  in  scarlet  fever  is  sometimes 
also  complicated  with,  or  rather  coexists  with,  cardiac  inflammation, 
pleuritis,  or  pneumonitis,  rendering  the  prognosis  more  unfavorable. 

In  rare  instances  the  acute  symptoms  of  rheumatism  abate,  but 
the  joints  remain  stiflf  and  more  or  less  swollen,  and  painful  when 
moved.  The  acute  has  lapsed  into  a  subacute  or 
chronic  rheumatism.  Such  a  case,  represented 
in  the  accompanying  figure,  was  brought  to 
the  children's  class  in  the  Out-door  Depart- 
ment at  Bellevue  Hospital,  in  February  1871. 
E.  H.,  female,  3|  years  old,  had  intermittent 
fever  from  the  age  of  nine  to  fifteen  months. 
From  this  time  she  remained  well  till  the  age 
of  two  years,  when  she  was  taken  with  acute 
rheumatism,  commencing  in  her  ankles  and 
extending  to  other  joints.  The  knee  and  hip 
joints  on  both  sides  have  only  partially  re- 
covered their  mobility,  and  both  legs  and  both 
thighs  are  permanently  flexed,  so  that  the  gait 
is  slow  and  unsteady.  It  is  impossible  to 
straighten  either  limb  without  causing  great 
pain,  and  attempts  to  straighten  the  thigh 
produce  the  arch  in  the  back  very  similar  to 
that  in  coxalgia. 

Diagnosis. — This  is  not  difficult  in  ordinary  cases,  if  a  proper 
examination  is  made.  In  the  commencement,  if  the  aftection  of 
the  joints  is  slight,  rheumatism  might  be  mistaken  for  remittent, 
typhoid,  one  of  the  eruptive  fevers,  or  meningitis;  but,  on  careful 
examination,  tenderness  will  be  observed  of  one  or  more  of  the 
articulations,  and  probably  some  swelling.  This  tenderness  is 
readily  distinguished  from  the  hypersesthesia  which  is  common  in 
the  first  stage  of  the  essential  fevers,  and  which  is  observed  when 
pressure  is  made  upon  the  chest  or  abdomen  as  well  as  upon  the 


282  ACUTE    RHEUMATISM. 

limbs,  and  is  more  marked  between  the  joints  than  in  them.  Any 
doubt  which  may  at  first  exist,  whether  the  patient  may  not  have 
one  of  those  diseases,  is  soon  dispelled,  since  their  clinical  history 
presents  notable  difterences  from  that  of  rheumatism. 

I  have  known  scrofulous  arthritis,  or  scrofulous  ostitis  near  the 
joint,  present  so  close  a  resemblance  to  acute  rheumatism  as  to 
be  at  first  mistaken  for  it.  In  one  instance  this  inflammation 
commenced  in  three  distinct  points,  so  that  the  difl'erential  diag- 
nosis at  first  was  difficult.  But  scrofulous  inflammation  as  well  as 
that  from  pyaemia  can  be  diagnosticated  from  rheumatic  disease  of 
the  joints,  by  its  greater  persistence,  less  induration  and  symmetry 
in  4;he  swelling,  and  by  the  history  of  the  case.  Chronic  rheuma- 
tism may  produce  deformity  similar  to  that  from  chronic  scrofulous 
inflammation,  as  in  the  case  detailed  above,  but  the  rheumatic 
history,  number  of  joints  aflected,  bilateral  character  of  the  in- 
flammation, good  general  health,  etc.,  are  sufficient  to  establish  a 
clear  diagnosis. 

Treatment. — The  theory  of  the  pathology  of  a  disease  deter- 
mines the  mode  of  treatment.  It  is  believed  that  rheumatism  is 
due  to  an  acid,  probably  lactic,  in  the  blood,  and  hence  alkaline 
remedies  are  commonly  employed,  with  the  apparent  eftect  of 
diminishing  the  severity  of  the  disease  and  shortening  its  dura- 
tion. The  tartrate  of  soda  and  potassa,  acetate  of  potassa,  and  the 
bicarbonate  of  soda  or  potassa,  may  be  given  singly  or  combined, 
according  to  the  condition  of  the  patient.  The  following  is  a  good 
formula  for  a  previously  healthy  child  of  six  or  eight  years: — 

R.  Potas.  et  sodse  tart,  ^^ss  ; 
Potas.  acetat.  5ij ; 
Syr.  limonum, 
Aquae,  aii  §iij.  Misce. 
Dose,  two  teaspoonfuls  every  two  or  three  hours. 

Sulphate  of  morphia,  Dover's  powder,  or  other  opiate,  is  ordina- 
rily required  in  the  evening  to  procure  rest  and  prevent  any  undue 
purgative  effect  of  the  medicine.  If  there  is  considerable  pain  in 
the  joints,  one  or  two  doses  of  the  same  should  be  given  through 
the  day.  If  there  is  a  tendency  to  diarrhoea,  or  a  state  of  debility, 
measures  of  a  more  sustaining  nature  are  required.  For  such 
cases  the  bicarbonate  of  soda  or  potassa  is  preferable  to  the  other 
alkalies. 

In  a  few  days,  by  the  alkaline  treatment,  the  urates  cease  to 
appear  in  the  urine,  and  the  disease  begins  to  decline.  There  is 
now  little  danger  that  any  complication  will  occur  if  the  internal 


TREATMENT.  283 

organs  have  so  far  escaped.  I  know  no  remedies  so  effectual  in 
relieving  not  only  rheumatic  inflammations  of  the  joints,  but  the 
general  muscular  tenderness  which  occurs  from  taking  cold,  and 
which  is  often  present  in  the  commencement  of  rheumatism,  as 
the  Rochelle  salts  and  acetate  of  potash. 

During  the  declining  period  of  rheumatism  and  in  convalescence, 
quinine  or  some  preparation  of  cinchona  should  be  employed,  and 
the  alkali  given  less  frequently.  This  tonic  does  indeed  appear  to 
exert  a  beneficial  effect  on  the  course  of  rheumatism,  and  it  is 
employed  by  some  judicious  and  experienced  physicians  from  the 
commencement,  as  the  main  remedy.  Certainly,  in  all  cases  of 
debility,  it,  or  a  similar  medicine,  should  be  early  employed,  unless 
contraindicated  by  some  complication. 

Rheumatism  impoverishes  the  blood,  and  the  patient  often  begins 
to  present  an  anaemic  appearance,  when  he  requires  iron  in  addi- 
tion to  the  vegetable  tonic.  The  citrate  of  iron  and  quinine  may 
then  be  employed. 

Secondary  rheumatism  requires  sustaining  treatment  from  the 
first.  Cases  occurring  in  my  practice  have  done  well  without 
alkalies,  and  with  the  general  supporting  measures  employed  for 
the  primary  disease. 

Pneumonitis  complicating  rheumatism  is  best  treated  by  mode- 
rate counter-irritation  and  emollient  poultices,  and  the  internal  use 
of  carbonate  of  ammonia;  or,  if  there  is  aneemia,  carbonate  of 
ammonia  with  citrate  of  iron  and  ammonia.  The  other  internal 
inflammations  which  are  liable  to  arise  as  complications  require 
iodide  of  potassium  in  decided  doses.  In  pericarditis  or  endo- 
carditis, if,  as  is  commonly  the  case,  the  movements  of  the  heart 
are  accelerated,  the  tincture  of  aconite  root,  or,  in  young  and 
debilitated  children,  tincture  of  digitalis,  is  required  to  the  extent 
of  reducing  the  number  of  pulsations  to  near  the  normal  fre- 
quency. A  child  of  six  years  can  take  one  drop  of  aconite,  or 
three  or  four  times  the  quantity  of  digitalis,  to  be  repeated,  if 
necessary,  in  three  hours,  till  the  required  reduction  of  the  pulse  is 
effected.  Patients  often  express  the  relief  from  the  palpitation  and 
dyspnoea  which  they  experience  by  the  use  of  these  agents. 

The  patient  should  be  kept  quiet,  in  a  room  of  uniform  tempera- 
ture, and  not  exposed  to  draughts  of  air.  By  such  precaution  the 
danger  of  complications  is  greatly  diminished.  Repellent  applica- 
tions, as  cold  or  irritants,  should  not  be  applied  to  the  joints,  as 
long  as  the  disease  is  acute,  for  they  also  increase  the  danger  of 
complications.  The  affected  joints  should  be  enveloped  in  flannel 
or  cotton,  and  the  pain,  if  intense,  may  be  diminished  by  applying 


28-i  ERYSIPELAS. 

flannel  wrung  out  of  warm  water.  If  the  disease  becomes  sub- 
acute or  chronic,  if  the  urates  have  disappeared  from  the  urine, 
and  the  inflammation  ceases  to  pass  from  joint  to  joint,  the  tinc- 
ture of  iodine,  or  moderately  stimulating  embrocations,  applied  to 
the  joints,  involve  no  danger  and  are  useful. 


CHAPTER  Y. 

ERYSIPELAS. 


The  term  erysipelas  is  applied  to  a  constitutional  or  blood  dis- 
ease, which  is  characterized  by  inflammation  of  the  skin  and 
subcutaneous  cellular  tissue,  and  by  a  tendency  to  spread.  It  is 
accompanied  by  a  burning  and  pricking  sensation,  swelling,  and 
subcutaneous  infiltration. 

In  rare  instances,  in  young  infants,  an  inflammation  which  has 
been  designated  erysipelas  occurs  in  and  around  the  umbilicus.  It 
commences  about  the  time  of  the  detachment  of  the  umbilical 
cord,  and  is  accompanied  by  redness  of  the  skin,  tumefaction,  and 
hardness  of  the  cellular  tissue  surrounding  the  umbilicus.  It 
usually  causes  ulceration  of  the  umbilical  fossa,  and,  in  fatal  cases, 
pus  is  sometimes  found  in  the  umbilical  vessels.  This  disease  does 
not  show  any  tendency  to  spread ;  the  diameter  of  the  inflamed 
surface  is  not  more  than  three  or  four  inches,  with  the  umbilicus 
at  the  centre.  It  is  generally  fatal  ;  but  two  favorable  cases  have 
been  reported  to  me,  in  one  of  which  there  was  considerable  ulcera- 
tion, and  after  recovery  a  firm  cicatrix  occupied  the  site  of  the 
umbilicus.  The  most  reasonable  view  is  that  this  disease  is  pri- 
marily an  inflammation  of  the  umbilical  fossa  and  vessels,  induced 
by  uncleanliness,  cachexia,  or  other  cause.  It  lacks  the  distin- 
guishing feature  of  erysipelatous  inflammations,  namely,  the  t.en- 
dency  to  spread,  and  I  shall  therefore  take  no  further  notice  of  it 
in  this  connection.     (See  Diseases  of  the  Umbilicus.) 

Erysipelas  seldom  occurs  in  childhood  ;  the  few  cases  which  are 
met  in  this  period  present  nearly  the  same  features,  and  pursue 
nearly  the  same  course,  as  in  the  adult.  In  infancy,  on  the  other 
hand,  erysipelas  is  not  a  rare  disease.  Every  practitioner  is  called 
to  cases,  from  time  to  time.  The  following  remarks  relate  to  ery- 
sipelas occurring  in  this  period  of  life.  My  views  have  been 
derived  mainly  from  the  records  of  cases  which  occurred  in  this 
city,  some  in  my  own  practice,  but  most  in  the  practice  of  other 


ERYSIPELAS. 


285 


physicians.     The  points  of  chief  interest  in  forty-one  cases  are 
embraced  in  the  following  table : — 

Cases  of  Infantile  Erysipelas. 


Q 

X 

Age. 

Point  of 

Parts  affected. 

Duration. 

Result. 

ti 

eg 
M. 

( 

jommencement. 

1 

5  muaths 

Right  knee 

Entire  surface,  except  face  aud  scalp           H  weeks  and 

Recovered. 

3  days 

2 

M. 

2  years 

Left  kneo 

From  a  littlo  above  the  knee  to  the  ankle 

7  days 

Recovered. 

3 

M. 

10  mouths 

Elhow 

Whole  arm  aud  forearm 

.... 

Recovered. 

4 

F. 

1  yeai-  iSi 
8  mouths 

13olow  right 
kuee 

Euiiro  leg,  thigh,  aud  trunk  to  the  um- 
bilicus 

7  days 

Itccovered. 

5 

F. 

9  mouths 

Vulva 

Abdomeu,  chest,  aud  all  the  extremities 

8  days 

Recovered. 

6 

M. 

9  days 

Genitals 

Both  lower  extremities,  abdomen  to  the 
umbilicus 

tj  days 

Died. 

7 

F. 

1  year 

Vulva 

Entire  surface,  except  face 

6  weeks 

Recovered. 

S 

F. 

6  weeks 

At  or  near  the 
ear 

Forehead  and  side  of  face 

1  week 

Died  in 
tetanic 
spasms. 

9 

'  • 

9  months 

Epigastric  re- 
gion 

Trunk  and  lower  extremities 

2  weeks 

Died  in 
tetanic 

spasms. 

10 

F. 

10  months 

At  angle  of 
mouth 

Entire  face  and  scalp 

10  days 

Recovered. 

11 

F. 

4  weeks 

Vulva 

Entire  surface,  except  face 

3  weeks 

Died. 

12 

F. 

3  months 

Vulva 

Surface   of    abdomen    to   umbilicus    and 
right  lower  extremity 

2  weeks 

Recovered. 

13 

F. 

4  toSmos. 

Vulva 

All  the  limbs  and  the  trunk,  except  the 

chest 

3  to  4  weeks 

Died. 

14 

F. 

6  months 

From  syphilitic 
sores  around 
auus 

Trunk  and  both  lower  extremities 

■  •  •  • 

.... 

13 

F. 

3  months 

Vulva 

Entire  trunk  and  both  upper  extremities 

3  weeks 

Recovered. 

lb 

M. 

8  months 

Face  near  nos- 
trils 

Entire  truuk  and  both  upper  extremities 

About  2 
Weeks 

Recovered. 

17 

F. 

4  months 

Vulva 

Entire  truuk  and  all  the  extremities 

1  week 

Died. 

18 

F. 

7  months 

Knee 

A  portion  of  trunk  and  both  lower  ex- 
tremities 

3  weeks 

Recovered. 

19 

F. 

6  months 

Near  the  ear 

Entire  face  and  forehead 

10  days 

Recovered. 

20 

M. 

7  days 

Left  eyelid 

Left  side  of  face 

:<  days 

Died. 

21 

M. 

14  days 

Genitals 

Extended  to  knees,  over  abdomen  to  the 
chest 

4  days 

Died. 

22 

M. 

3  months 

Under  the  chin 

Chin,  left  cheek,  neck,  left  side  of  trunk, 
left  thigh,  aud  leg 

.... 

.... 

23 

F. 

2  years  & 
4  mouths 

Right  shoulder 

Arm  and  forearm 

1  day 

Died  in  con- 
vulsions. 

24 

F. 

3  or  4  days 

Vulva 

Body  and  all  the  limbs 

12  days 

Died. 

25 

F. 

3^  months 

Under  left  ear 

Neck,  chest,  and  arms 

About  2 

weeks 

Died. 

26 

•• 

7  months 

Below  right 
knee 

Trunk,  neck,  and  head,  and  all  the  limbs 

2  weeks 

Died  coma- 
tose. 

27 

F. 

6  months 

Vulva 

Both  thighs,  and  nearly  entire  trunk 

3  days 

Died  coma- 
tose. 

28 

M. 

19  months 

Near  point  of 
vaccination 

Shoulder,  arm,  and  forearm 

21  days 

Recovered. 

29 

M. 

4  months 

Near  point  of 
vaccination 

Chest,  and  both  upper  limbs 

2  weeks 

Recovered. 

30 

F. 

2  months 

Near  vaccine 
vesicle 

Trunk,  and  all  the  limbs 

10  days 

Died. 

31 

•• 

3  to4mos. 

Near  vaccine 
vesicle 

Arm,  forearm,  and  shoulder  on  one  side 

2  to  3  weeks 

Died. 

32 

F. 

4  months 

Near  vaccine 
vesicle 

Arm,  forearm,  and  truuk 

2  mouths 

Died. 

33 

M. 

2  months 

Near  vaccine 
vesicle 

Nearly  entire  surface 

1  week 

Died  with 
peritonitis. 

34 

M. 

5^  months 

Near  poiut  of 
vaccination 

Arm  and  forearm 

.... 

Recovered. 

35 

M. 

2i  months 

Near  poiut  of 
vaccination 

Arm 

7  days 

Died  prob- 
ably of 
peritonitis. 

3f 

)   M. 

8  months 

Near  vaccine 
vesicle 

Arm  and  forearm 

17  days 

Died. 

3' 

5  months 

Left  foot 

Leg,  thigh,  and  lower  part  of  trunk 

2  weeks 

Died  with 
pueumo- 
nitis. 

3f 

)    . . 

5  weeks 

At  one  ear 

Entire  surface 

2  weeks 

Recovered. 

31 

4      .. 

2  mouths 

^   Left  leg 

Truuk,  and  all  the  limbs 

2  weeks 

Recovered. 

4( 

)      .. 

4  month 

i   Near  point  of 
vaeciuaiion 

Trunk,  and  all  the  limbs 

2  weeks 

Died. 

4 

.    M. 

14  month 

i   Face 

Trunk,  and  all  the  limbs 

4  weeks 

Recovered. 

286  ERYSIPELAS. 

Age. — Of  the  above  cases,  27  were  under  the  age  of  six  months  ; 
9  from  six  montlis  to  twelve,  and  only  5  above  the  latter  age.  A 
large  majority,  therefore,  of  cases  of  infantile  erysipelas  occur  in 
the  first  year  of  life. 

Point  of  Commencement. — In  58  cases  in  which  I  have  ascer- 
tained the  point  of  commencement,  it  was  in  13  cases  the  vulva,  17 
the  arm  after  vaccination,  7  the  leg,  6  the  face,  3  the  male  genital 
organs,  3  at  or  near  the  ear,  1  the  elbow,  1  the  shoulder,  1  the 
nates,  1  the  foot.  In  the  adult,  idiopathic  erysipelas  commonly 
commences  upon  the  face,  and  aflects  only  the  face,  ears,  forehead 
and  scalp.  On  the  other  hand,  in  infantile  erysipelas,  statistics 
show  that  the  rash  commences  upon  the  face  only  in  a  small  pro- 
portion of  cases,  one  in  nine,  and  that  it  rarely  extends  to  the  face 
when  it  commences  in  other  parts. 

Causes. — In  erysipelas  the  first  departure  from  the  healthy  state 
occurs  in  the  blood,  or  the  system  generally.  This  undergoes  cer- 
tain changes  which  predispose  to  erysipelas,  or  are  sufficient  in 
themselves  to  give  rise  to  it.  Among  the  causes  which  produce 
this  state  of  system,  uncleanliness,  residence  in  damp,  dark,  and 
crowded  apartments,  and  defective  alimentation,  hold  a  principal 
place.  Hence  this  disease  is  more  common  in  the  poor  quarters 
of  the  city  than  in  the  country,  and  in  dispensary  and  hospital 
than  in  civil  practice. 

In  a  large  proportion  of  cases  there  is  a  local  exciting  cause  of 
the  erysipelatous  eruption,  namely,  an  irritation  or  inflammation 
at  some  point,  generally  trivial,  but  which  is  sufiicient  to  develop 
the  disease  in  the  system  already  prepared  for  it.  It  is  very  apt  to 
commence  at  or  near  a  simple  ecthymatous  or  impetiginous  erup- 
tion, around  burns  or  suppurating  sores  or  syphilitic  eruptions ;  it 
frequently  commences,  as  is  seen  by  the  above  table,  near  the  point 
of  vaccination  immediately  after  vaccination,  or  when  the  pock  is 
developed,  or  again  when  it  has  run  its  course  and  been  detached. 
In  a  considerable  proportion  of  cases  it  commences  at  a  point  where 
the  skin  is  thin  and  delicate,  or  where  it  unites  with  a  mucous 
surface,  probably  from  some  uncleanliness  or  irritation  of  those 
parts.  Thus,  I  have  records  of  cases  in  which  it  commenced  at 
the  external  ear,  commissure  of  the  mouth,  and  at  the  vulva.  In- 
deed, the  frequency  with  which  it  commences  at  the  vulva  renders 
female  infants  more  liable  to  it  than  males.  In  some  instances 
erysipelas  begins  without  any  local  exciting  causes,  upon  smooth 
and  sound  skin,  even  when  there  are  sores  upon  various  parts  of 
the  surface. 


CAUSES.  287 

Vaccination,  as  an  exciting  cause  of  erysipelas,  demands  particu- 
lar notice.  Often,  doubtless,  it  is  the  inflammation,  wliicli  neces- 
sarily arises  from  tlic  cut  or  the  vesicle,  which  operates  as  an 
exciting  cause  of  the  erysipelatous  affection,  and  not  any  delete- 
rious property  contained  in  the  virus  which  is  employed,  so  that 
an  equal  degree  of  inflammation  occurring  in  any  other  way,  as 
from  a  burn,  would  be  attended  by  a  like  result.  But  facts  show 
that  the  virus  itself  occasionally  contains  a  latent  noxious  prin- 
ciple, which,  introduced  into  the  system,  operates  as  a  cause  of 
erysipelas.  Thus,  a  little  girl  was  vaccinated  by  me  in  ISTovember, 
1860,  and  about  the  time  when  the  vesicle  began  to  fill  she  was 
seized  with  severe  inflammation  of  the  fauces,  attended  by  tume- 
faction and  infiltration  of  the  submucous  connective  tissue.  The 
inflammation  rapidly  subsided,  and  within  a  week  from  its  com- 
mencement the  throat  affection  had  nearly  or  quite  disappeared. 
I  now  believe  that  the  disease  of  the  fauces  was  erysipelatous, 
although  it  was  not  suspected  at  the  time  to  have  this  character. 

As  the  girl  was  otherwise  healthy,  and  the  vaccine  vesicle  passed 
through  its  usual  stages,  and  presented  the  usual  appearance,  the 
scab  was  employed  six  weeks  afterwards  to  vaccinate  two  infants. 
Within  twenty-four  hours  after  vaccination  both  these  infants  were 
seized  with  high  fever,  ushering  in  severe  erysipelas,  commencing  in 
one  around  the  point  of  vaccination,  and  in  the  other  around  syphi- 
litic sores  near  the  anus.  In  the  former  case  the  erysipelatous  rash 
extended  from  the  shoulder  over  the  entire  limb,  and  was  obstinate, 
twice  reappearing,  and  extending  over  the  same  surface ;  in  the 
latter  (a  mulatto  child)  it  extended  over  both  lower  extremities 
and  a  considerable  part  of  the  trunk,  when  the  case  passed  into  the 
hands  of  another  physician,  and  the  result  is  not  known.  The 
instrument  with  which  the  vaccinations  were  performed  was  clean. 
The  vaccine  disease  did  not  appear  in  either  of  these  cases. 

Again,  a  well-known  physician  of  this  city  vaccinated  three 
infants,  one  his  own  [l^o.  32  of  the  table),  with  part  of  a  scab 
which  had  been  pronounced  good,  but  was  taken  from  a  child  that 
he  had  not  seen,  and  with  whose  state  he  was  not  familiar.  These 
infants  were  all  affected  with  erysipelas  from  the  vaccination,  his 
own  dying.  He  had  taken  the  precaution  to  rub  the  lancet  on  his 
boot  before  using  it.  Another  physician  of  this  city  has  informed 
me  that  he  vaccinated  two  children  in  the  same  family  with  a 
scab,  with  all  the  precautions  that  he  had  ever  used,  and  both  were 
soon  after  aft'ected  with  erysipelas  of  a  severe  form,  extending 
from  the  point  of  vaccination ;  the  vaccine  disease  did  not  appear. 


288  ERYSIPELAS. 

I  know  of  no  case  in  which  the  vaccine  lymj^h  gave  rise  to  ery- 
sipelas, and,  probably,  it  rarely  or  never  does.  In  the  lymph  there 
is  no  admixture  of  foreign  substances,  whereas  in  the  scab  there 
is  a  large  proportion  of  animal  matter. 

There  is  a  form  of  erysipelas  which  occurs  in  the  infant  imme- 
diately after  birth,  and  which  is  sometimes  met  in  private  prac- 
tice, but  is  most  frequently  observed  as  an  epidemic  in  lying-in 
wards.  It  is  associated  with  severe,  and  commonly  fatal,  puer- 
peral fever  (metro-peritonitis),  or  erysipelas  of  the  mother.  This 
form  of  erysipelas  is  fatal,  almost  without  exception,  and  its  con- 
tagiousness is  generally  admitted  by  those  who  have  had  an  oppor- 
tunity to  observe  cases. 

A  case  showing  this  relation  of  erysipelas  in  the  newly-born 
infant  to  disease  of  the  mother  occurred  in  the  practice  of  Dr. 
Leaming,  of  this  city.  A  woman  gave  birth  to  a  healthy  infant, 
on  the  27th  of  July,  1860.  A  few  days  subsequently  she  was  seized 
with  a  chill,  followed  by  erysipelas,  commencing  on  the  thighs,  and 
terminating  fatally  August  17th.  As  no  autopsy  was  allowed,  the 
state  of  the  internal  organs  was  not  ascertained.  A  few  days  be- 
fore her  death  the  same  disease  commenced  on  the  infant.  It  ex- 
tended around  the  neck,  upon  the  ears,  down  the  arms,  and  termi- 
nated fatally  August  24th.  But  erysipelas  in  the  new-born  infant 
occurring  in  connection  with  erysipelas  in  the  mother,  is  more  rare 
than  its  occurrence  with  puerperal  fever.  The  records  of  lying-in 
asylums  furnish  many  examples  of  epidemics  of  puerperal  fever,  in 
which  the  infants  of  aftected  mothers  perish  of  erysipelas. 

The  late  Dr.  Folsom,  of  this  city,  furnished  me  the  following 
sketch  of  cases  which  occurred  in  his  practice  and  that  of  his 
partner:  "About  the  year  1840,  being  then  in  practice  in  !N"ew 
Bedford,  Mass.,  I  was  called  to  visit  a  man  who  complained  of 
pain  in  the  knee.  The  next  morning  he  was  easier,  but  the  fol- 
lowing evening  his  symptoms  grew  worse,  and  as  I  was  engaged 
in  a  case  of  obstetrics,  my  partner.  Dr.  E.  C,  now  dead,  visited 
him.  At  my  call,  next  morning,  I  unexpectedly  found  the  patient 
dying.  The  disease  was  obscure,  and  at  the  autopsy  next  day  no 
lesion  was  discovered.  In  making  the  examination.  Dr.  C.  pricked 
his  finger,  and  experiencing  little  inconvenience  from  it  at  first, 
he  attended  a  case  of  confinement  on  the  following  morning.  A 
few  hours  subsequently  he  was  taken  sick,  and  I  took  charge  of 
the  lady,  who  died  in  three  days,  having  the  tumid  abdomen  and 
symptoms  of  childbed  fever.     The  infant  of  the  patient  was  seized, 


PREMONITORY    SYMPTOMS.  289 

when  two  clays  old,  witli  erysipelas,  appearing  on  the  face  and  in 
spots  on  the  trunk  and  limbs,  and  terminating  fatally  in  one  day. 
Dr.  C.'s  finger  became  swollen  and  painful,  and  the  lymphatics  of 
the  forearm  and  arm  became  inflamed,  presenting  red  lines,  and 
the  axillary  glands  suppurated.  Though  feverish  and  much  pros- 
trated, there  was  no  appearance  of  erysipelas  in  his  case.  In  about 
two  weeks  he  resumed  practice,  and  as  at  that  time  ph3'sicians  in 
this  country  were  not  fully  aware  of  the  danger  of  communicating 
puerperal  fever,  he  attended  two,  three,  or  four  obstetrical  cases 
each  week,  until  the  number  reached  fifteen.  All  the  mothers 
died  with  symptoms  of  metro-peritonitis,  and  all  the  infants  had 
erysipelas,  commencing  on  the  face  or  some  part  of  the  body, 
generally  on  the  second  or  third  day  after  birth,  and  in  all  termi- 
nating fatally  within  a  week.  This  sad  record  was  finally  ended 
by  the  doctor's  temporarily  retiring  from  practice." 

Dr.  Condie,  in  his  Treatise  on  Diseases  of  Children,  says  :  "  Ery- 
sipelas of  infants  very  commonly  occurs  during  the  prevalence  of 
epidemic  puerperal  fever.  Children  of  mothers  who  become  af- 
fected with  the  fever  are  often  born  with  erysipelatous  inflamma- 
tion ;  others  are  attacked  almost  immediately  after  birth.  Whether, 
in  these  cases,  the  disease  is  to  be  referred  to  a  morbid  matter  ap- 
plied to  the  skin  in  the  womb,  or  to  the  same  epidemic  or  endemic 
influence  which  gives  rise  to  the  disease  of  the  parent,  it  is  diffi- 
cult to  say.  According  to  M.  Trousseau,  infantile  erj^sipelas  is 
principally  observed  when  puerperal  fever  prevails  in  the  wards  of 
the  lying-in  hospitals  at  Paris."  In  private  practice  it  is  rare  that 
we  meet  erysipelas  of  the  infant  associated  with  erj'sipelas  or  with 
puerperal  fever  in  the  mother.  Some  of  the  oldest  physicians  of 
this  city,  with  whom  I  have  conversed,  and  who  are  engaged  in 
extensive  general  practice,  state  that  they  have  never  met  a  case 
in  which  there  was  this  relation.  Cases  like  those  observed  by  Drs. 
Folsom  and  Leaming  only  occur  when  epidemic  erysipelas  or  puer- 
peral fever  is  prevailing. 

Premonitory  Symptoms. — Infantile  erysipelas  in  certain  cases  has 
no  premonitory  stage,  or,  if  present,  it  escapes  notice.  In  other  in- 
stances there  are  well-marked  precursory  symptoms,  as  drowsiness, 
or  restlessness,  febrile  movement,  oppressed  respiration,  with  per- 
haps vomiting,  and  starting  or  twitching  of  the  limbs.  In  Cases 
28  and  37  of  the  table,  which  occurred  in  my  practice,  the  febrile 
movement,  restlessness,  and  o^jpressed  respiration  were  so  great  for 
three  days  before  the  appearance  of  the  eruption,  as  to  cause  much 
anxiety.  In  the  adult,  pharyngitis  often  precedes  the  occurrence 
19 


290  ERYSIPELAS. 

of  the  rash  upon  the  skin.  The  same  inflammation  may  be  present 
in  the  premonitory  period  of  infantile  erysipelas,  as  well  as  during 
the  period  of  erysipelatous  eruption.  The  hurried  and  diflicult 
resj)iration,  which  is  present  in  the  commencement  of  some  cases, 
is  probably  due  to  an  erysipelatous  turgescence  of  the  bronchial 
mucous  membrane. 

Symptoms. — The  patient  with  this  disease  is  usually  restless,  in 
consequence  of  the  burning  pain  which  accompanies  the  eruption. 
In  severe  cases  there  is  little  sleep,  night  or  day,  except  from  medi- 
cine. The  sleep  is  short,  and  is  often  interrupted  by  sudden  start- 
ing, or  twitching  of  the  limbs.  Convulsions  may  occur,  but  are  not 
common. 

Febrile  movement  is  constant,  and  is  proportionate  to  the  extent 
and  gravity  of  the  erysipelas.  I  have  notes  of  cases  in  which  the 
pulse  was  more  than  200  per  minute,  although  other  symptoms 
did  not  indicate  immediate  danger.  The  skin  not  aifected  by  ery- 
sipelas is  dry  and  hot,  though  not  possessing  the  pungent  heat  of 
the  inflamed  portion ;  face  often  flushed ;  tongue  moist,  and  covered 
with  a  light  fur;  stomach  usually  retentive.  The  state  of  the 
bowels  varies ;  sometimes  they  are  regular,  sometimes  variable, 
while  in  other  cases  the  stools  are  green,  and  more  frequent  than 
natural.  I  have  records  relating  to  the  state  of  the  bowels  in 
twenty  cases,  as  follows :  in  seven,  regular ;  in  nine,  loose  ;  in  two, 
constipated  ;  in  one,  constipated,  then  loose ;  and  in  one,  consti- 
pated, then  regular.  Diarrhoea,  when  present,  is  usually  mild, 
requiring  little  or  no  treatment.  The  erysipelatous  redness  is  not 
in  all  cases  so  pronounced  as  in  the  adult,  but  otherwise  there  is 
nothing  peculiar  in  its  appearance.  In  feeble  infants,  with  an  im- 
poverished state  of  the  blood,  its  color  is  pink,  instead  of  the  deep 
red  which  characterizes  the  inflammation  in  the  robust.  Points 
of  vesication  may  occur  where  the  inflammation  is  most  severe,  as 
in  the  adult,  and  subsequently  the  same  desquamation  and  oedema. 

If  the  infant  is  debilitated,  there  is  great  danger  of  the  forma- 
tion of  abscesses,  around  which  the  inflammation  lingers  after  it 
has  disappeared  from  every  other  part  of  the  body.  Sometimes 
also,  in  very  young  infants,  gangrene  occurs,  especially  of  the  geni- 
tal organs  in  the  male.  Several  of  these  cases  have  been  related  to 
me,  all  under  the  age  of  a  month  or  six  weeks,  and  all  fatal.  Oc- 
casionally the  sloughing  is  so  great  as  to  denude  the  testicles.  A 
noteworthy  feature  of  erysipelas  in  infants  is  its  proneness  to 
return.  "When  it  has  been  progressively  subsiding,  and  hope  is 
entertained  of  its  speedy  disappearance,  it  not  infrequently  is  sud- 


PROGNOSIS  —  DURATION.  2P1 

denly  relighted  from  some  unknown  cause,  travelling  again  over  the 
same,  or  parts  of  the  same,  surface.  In  one  case  the  disease,  arising 
from  vaccination,  extended  three  times  over  the  arm  and  forearm ; 
and  in  another  case,  a  second  time  over  both  legs  and  a  considerable 
part  of  the  trunk. 

The  internal  inflammations,  which  most  frequently  complicate 
erysipelas,  and  give  rise  to  symptoms  which  are  superadded  to  those 
pertaining  to  the  erysipelas,  are  pharyngitis  and  peritonitis ;  and 
more  rarely  broncho-pneumonia  or  enteritis.  In  a  case  which  I  ex- 
amined after  death,  in  the  Nursery  and  Child's  Hospital,  and  in 
which  the  erysipelatous  inflammation  having  extended  over  the 
abdomen,  the  lesions  of  peritonitis  were  present,  it  seemed  probable, 
from  the  thinness  of  the  abdominal  walls,  that  the  inflammation 
had  extended  through  the  parietes  from  the  external  to  the  internal 
surface. 

Prognosis. — Erysipelas  is  much  more  fatal  in  infancy  than  in 
adult  life.  In  the  death  statistics  of  this  city  for  three  years,  I 
find  eighty  deaths  from  erysipelas  of  infants  under  the  age  of  one 
year,  to  eighty-three  deaths  from  this  disease  above  that  age.  Age 
greatly  influences  the  prognosis.  Infants  under  the  age  of  three 
weeks  usually  die  ;  from  the  age  of  three  weeks  to  six  months  the 
result  is  doubtful ;  while  above  the  age  of  six  months  a  majority 
recover  with  correct  treatment.  It  will  be  seen  by  the  foregoing 
table  that  seven  infants  under  the  age  of  six  weeks  had  erysipelas, 
and  six  died ;  from  the  age  of  six  weeks  to  six  months,  six  recov- 
ered and  nine  died ;  and  above  the  age  of  six  months,  nine  recovered 
and  four  died. 

With  the  exception  of  a  case  of  the  so-called  umbilical  erysipe- 
las, the  youngest  child  who  recovered,  of  whom  I  have  obtained 
information,  was  three  weeks  old.  In  this  case  the  rash  extended 
nearly  over  the  entire  surface,  beginning  with  the  face.  Case  38 
of  the  table,  treated  by  myself,  was  very  similar  as  regards  the 
extent  of  the  erysipelatous  eruption  and  the  result.  This  infant 
was  five  weeks  old. 

It  is  scarcely  necessary  to  state  that  erysipelas  is  more  favorable 
when  it  aflfects  the  limbs  than  when  it  invades  the  head,  neck,  or 
body  ;  when  it  spreads  slowly  than  rapidly ;  when  it  is  superficial 
than  when  phlegmonous.  In  those  cases  in  which  the  connective 
tissue  is  much  involved,  the  infant  is  not  always  safe  after  the 
disease  has  run  its  course ;  he  sometimes  dies  exhausted  from  the 
discharge  of  abscesses :  I  have  records  of  two  such  cases. 

Duration. — In  sixteen  cases  that  recovered,  the  disease  termi- 


292  ERYSIPELAS. 

nated  within  the  first  week  in  two,  the  second  week  in  six,  the 
third  week  in  five,  fourth  week  in  one,  and  in  two  cases  it  lasted  five 
and  six  weeks.  The  average  duration  was  fi/teen  days.  In  nine- 
teen fatal  cases,  ten  died  within  the  first  week,  five  the  second 
week,  three  the  third  week,  and  one  in  the  fourth  week.  The 
average  duration  of  fatal  cases  was  about  ten  days. 

Modes  of  Death. — Death  occurs  in  dififerent  ways ;  in  clonic  or 
tonic  convulsions  followed  by  coma,  from  exhaustion,  and  from 
internal  inflammation,  that  from  exhaustion  being  probably  the 
most  common. 

Pathological  Anatomy. — The  blood  doubtless  in  this  disease 
undergoes  certain  pathological  alterations  previously  to  the  oc- 
currence of  the  eruption,  but  the  exact  changes  are  not  known. 
Our  knowledge  of  the  morbid  anatomy  of  erysipelas  relates  chiefly 
to  the  local  affections,  which,  with  the  exception  of  the  inflamma- 
tion of  the  skin,  are  not  constant,  and  may,  therefore,  be  regarded 
as  complications.  The  cutaneous  inflammation  affects  all  the 
structures  of  the  skin,  and  in  greater  or  less  degree  also  the  sub- 
cutaneous connective  tissue.  The  inflammation  is  accompanied  by 
more  or  less  serous  effusion  or  oedema. 

The  not  infrequent  occurrence  of  peritonitis  in  connection  with 
erysipelas  has  long  been  known.     In  Heberdeu's  Epitome  Morbo- 
rum  Pueriliumy  the  anatomical  character  of  erysipelas  is  expressed 
in  one  sentence:  "When  the  body  has  been  opened  after  death, 
the  intestines  have  been  found  glued  together  and  covered  with 
coagulable  lymph."     Since  Heberden's  time,  nearly  all  who  have 
written   on  diseases  of  infancy  and   childhood  have  mentioned 
peritonitis  as  one  of  the  most  common  complications.     Under- 
wood says :  "  Upon  examining  several  bodies  after  death,  the  con- 
tents of  the  body  have  frequently  been  found  glued  together  and 
their  surface  covered  with  inflammatory  exudation,  exactly  similar 
to  that  of  women  who  have  died  of  puerperal  fever."     Similar 
remarks  in  reference  to  the  frequency  of  peritonitis  in  this  disease 
are  made  by  recent  writers. 

The  statistics  in  reference  to  this  disease  appear  to  demonstrate 
that  in  infants  in  hospital  practice,  and  in  those  affected  by  ery- 
sipelas during  epidemics  of  puerperal  fever,  peritonitis  is  a  not 
infrequent  complication.  On  the  other  hand,  as  wo  commonly 
meet  cases  of  infantile  erysipelas  occurring  sporadically  in  private 
practice,  there  is  not  sufficient  abdominal  distension  and  tender- 
ness for  peritoneal  inflammation.  In  only  one  of  the  cases  em- 
braced in  the  foregoing   table  was  a  post-mortem   examination 


TREATMENT,  293 

made,  and  in  that  there  had  l)ecn  no  peritonitis.  The  occurrence 
of  pharj^ngitis  in  connection  with  erysipelas  has  been  ah'cady  al- 
luded to. 

Enteritis  has  been  alluded  to  as  another  complication  in  infants. 
Diarrhcea  has  been  stated  to  be  a  symptom  in  certain  cases  ;  it  has 
been  found  to  be  dependent  on  enteritis  of  a  mild  grade.  Billard 
made  post-mortem  examinations  of  sixteen  cases  of  infants  dying 
of  erysipelas,  and  "found  in  two  gastro-enteritis,  in  ten  enteritis, 
in  three  pneumonia  complicated  with  enteritis  and  cerebral  con- 
gestion, and  in  one  pleuro-pneumonia." 

Treatment. — On  this  side  of  the  Atlantic  great  uniformity  pre- 
vails as  regards  the  treatment  of  erysipelas.  Sustaining  measures 
are  prescribed,  and  the  tincture  of  the  chloride  of  iron  is  the  tonic 
generally  preferred.  Whatever  the  intensity  of  the  febrile  reac- 
tion and  the  stage  of  the  disease,  if  there  is  no  intestinal  compli- 
cation, ferruginous  or  other  tonics  should  be  administered.  The 
largest  doses  of  the  tincture  of  the  chloride  of  iron  given  in  any  of 
the  cases  in  the  above  table  were  in  case  ISTo.  4,  namely,  ten  drops 
every  two  hours,  and  this  patient  recovered  in  seven  days  from  a 
pretty  severe  attack.  Probably,  however,  nothing  is  gained  by 
such  large  doses,  and  they  may  irritate  the  intestinal  surface,  and 
increase  the  liability  to  enteritis,  which,  we  have  seen,  complicates 
a  certain  proportion  of  cases.  Two  drops  may  be  given  every  three 
hours  to  a  child  from  one  to  two  years  of  age.  Instead  of  the 
iron,  or  in  addition  to  it,  one  of  the  preparations  of  cinchona  may 
be  prescribed.  Beef-tea,  and  in  most  cases  wine-whey  or  other 
alcoholic  stimulant,  are  required. 

The  depressing  measures  recommended  by  certain  writers  cannot 
be  too  strongly  censured.  Bouchut  says:  "We  should  endeavor 
from  the  first  to  allay  the  inflammation  of  the  skin  by  energetic 
treatment.  .  .  .  Local  abstraction  of  blood,  by  means  of  one 
or  two  leeches  applied  at  the  circumference  of  the  primary  seat  of 
the  erysipelas,  should  be  put  in  force,  provided  the  power  of  the 
constitution  of  the  children  permits."  Such  treatment  may  ex- 
plain one  of  Bouchut's  aphorisms,  namely,  the  erysipelas  of  infants 
is  a  fatal  disease. 

Local  treatment  may  be  employed  to  arrest  the  extension  of  the 
inflammation,  but  the  result  in  most  cases  is  not  encourao'ino-. 
Solid  nitrate  of  silver  was  employed  in  two  cases,  of  which  I  have 
records,  and  in  both  the  result  was  pernicious.  Troublesome  sores 
were  produced,  from  which  blood  escaped,  and  in  one  of  the  cases, 


29-i  ERYSIPELAS. 

at  least,  death  was  attributed  by  the  parents  to  this  treatment, 
rather  than  to  the  disease. 

Tincture  of  iodine  is  a  better  remedy  for  arresting  the  exten- 
sion of  erysipelas.  It  should  be  applied  from  the  margin  of  the 
inflammation,  over  the  sound  skin,  to  the  distance  of  about  two 
inches.  It  may  be  ineffectual,  but  it  does  not  produce  any  unfa- 
vorable result.  Soothing  applications,  like  rye  flour,  or  a  lotion  of 
sugar  of  lead,  may  be  made  to  the  inflamed  surface,  as  in  erysipe- 
las of  the  adult.  I  prefer,  however,  for  local  treatment,  the  con- 
stant application  of  glycerine,  or  glycerine  and  water,  to  which  a 
few  drops  of  carbolic  acid  are  added. 


PART  III. 


SECTIONS"  I. 

DISEASES  OF  THE  CEEEBRO-SPINAL  SYSTEM. 

Diseases  of  the  brain  and  spinal  cord  are  less  frequent  than 
those  of  the  respiratory  and  digestive  systems.  They  are  also  less 
amenable  to  treatment,  and  are  much  more  fatal.  They  largely 
increase  the  aggregate  of  deaths.  They  contrast  with  the  diseases 
of  the  other  systems  in  their  greater  relative  frequency  in  infancy 
and  childhood  than  in  adult  life.  This  is  explained,  as  regards  the 
brain,  by  the  rapid  develojjment  of  this  organ  in  early  life,  its 
feeble  consistence,  its  great  impressibility  by  the  emotions,  and  the 
thinness  of  the  covering  which  protects  it  from  external  agencies. 

Some  of  the  most  interesting  of  the  cerebro-spinal  diseases 
which  are  to  engage  our  attention,  are  peculiar  to  early  life,  as 
tetanus  nascentium.  The  diseases  of  this  system  also  contrast 
with  other  local  afiections  in  their  greater  obscurity,  especially  in 
their  commencement ;  for  while  diseases  of  the  thorax  can  be 
readily  ascertained  by  auscultation  and  percussion,  or  those  of  the 
abdomen  by  the  nature  of  the  evacuations  or  the  degree  of  tender- 
ness or  distension,  our  means  of  conducting  examination  through 
the  bony  encasement  of  the  cerebro-spinal  axis  are  meagre  and 
unsatisfactory.  The  condition  of  the  brain  and  spinal  cord  must 
be  determined,  chiefly,  by  the  study  of  symptoms,  and  not  by 
direct  examination.  The  condition  of  the  anterior  fontanelle  in 
young  infants,  however,  enables  us  to  determine  the  presence  or 
absence  of  active  cono-estion  of  the  brain.  If  there  is  an  excess  of 
arterial  blood,  it  is  convex.  Prominence  of  the  fontanelle  is  com- 
mon in  inflammatory  and  febrile  diseases,  and  is  a  sign  of  con- 
siderable diagnostic  and  prognostic  value. 

Within  a  few  years,  the  ophthalmoscope  has  been  employed  as  a 
means  of  diagnosis  in  cerebral  diseases,  and  although  the  employ- 
ment of  this  instrument  for  such  purpose  is  but  recent,  enough  has 


296  DISEASES    OF    THE    CEREBEO -SPINAL    SYSTEM. 

been  elicited  to  prove  its  great  value  as  an  aid  in  determining  the 
state  of  the  brain.  Prof.  H.  D.  l^oves  remarks  on  this  subject : 
"...  The  argument  for  making  ophthalmoscopic  examination  in 
all  cases  of  brain  disease,  becomes  irresistible.  Indeed,  a  moment's 
reflection  would  lead  to  this  conclusion  without  any  considerations 
drawn  from  pathology.  The  optic  nerve  is  only  an  outlying  por- 
tion of  the  brain ;  its  extremity  is  fully  exposed  to  view.  Situated 
within  about  two  inches  of  the  brain,  it  is  the  only  nerve  in  the 
body  which  we  can  inspect ;  it  contains  bloodvessels  which  com- 
municate directly  with  the  intra-cranial  circulation.  We  thus 
come  into  relation  with  the  cerebrum,  by  continuity  of  nerve- 
structure  and  also  of  bloodvessels." 

Structural  changes  in  the  optic  nerve  and  retina  have  been 
discovered  by  means  of  the  ophthalmoscope  in  meningitis,  hydro- 
cephalus, phlebitis  of  the  sinuses,  apoplexy,  etc.  Among  the 
lesions  which  have  been  observed  by  this  instrument,  are  hype- 
reemia,  more  or  less  opacity  and  tumefaction  of  the  optic  nerve, 
engorgement  of  the  vessels  of  the  retina,  with  serous  or  sero- 
fibrinous exudation  and  ecchymotic  points.  In  certain  protracted 
diseases,  as  chronic  hydrocephalus,  in  which  dimness  or  loss  of 
sight  occurs,  the  ophthalmoscope  discloses  a  state  of  atrophy  of 
the  optic  nerve.  Heretofore  the  ophthalmoscope  has  been  chiefly 
employed  by  oculists,  but  as  it  comes  into  more  general  use,  there 
can  be  little  doubt  that  it  will  be  recognized  as  an  important  aid 
in  the  diagnosis  of  obscure  cerebral  diseases. 

Still,  with  all  possible  aids  to  diagnosis,  the  obscurity  which 
attends  the  invasion  of  many  of  the  cerebro-spinal  diseases  must 
be  acknowledged.  To  the  hasty  and  careless  physician,  their 
symptoms  are  often  deceptive.  Careful  weighing  of  the  phe- 
nomena, and  thorough  and  protracted  examination,  are  requisite  in 
order  to  insure  correct  diagnosis  and  proper  treatment.  Some  of 
the  cerebro-spinal  affections  are,  in  reality,  sequelae  of  other  dis- 
eases, as,  for  example,  spurious  hydrocephalus;  and  some  are, 
strictly  speaking,  only  symptoms,  as  convulsions ;  but,  on  account 
of  their  importance,  and  because  they  require  special  treatment,  it 
is  proper  to  consider  them  as  diseases  ])er  se. 

The  brain  presents  certain  peculiarities  in  infancy  and  childhood. 
In  the  foetus,  while  the  other  oi*gans  are  well  formed,  the  brain, 
especially  its  cerebral  portion,  is  still  diffluent,  and  at  birth  it  has 
so  little  consistence  tliat  it  must  be  handled  carefully  to  prevent 
laceration.     This  softness  is  due  to  the  large  proportion  of  water 


DISEASES    OF    THE    CEREBRO- SPINAL    SYSTEM.  297 

which  it  contains.     The  following  analyses  show  the  composition 
of  the  hrain  in  the  three  periods  of  life: — 

Infant.  Youth.  Adult. 

Albumen 7.00  10.20  9,40 

Cerebral  fats 3.45  5.30  6.10 

Phospliorus 80  1.65  1.80 

Osmazone,  salts 5.9G  8.59  10.19 

Water 82.79  74.26  72.51 

At  birth  the  brain  has  a  nearly  uniform  white  color.  The  gray 
substance,  in  which  the  nervous  power  originates,  is  undeveloped. 
The  date  of  its  appearance  corresponds  with  the  first  exhibition  of 
emotion  or  intelligence,  and  the  decided  gray  color  which  we 
observe  in  the  brain  of  the  adult  does  not  appear  until  the  age  of 
full  mental  activity. 

In  the  new-born  the  brain  is  large  in  proportion  to  the  rest  of 
the  body,  and  its  growth  during  infancy  and  childhood  is  rapid. 
Until  the  fifth  year,  as  appears  from  the  observations  of  Dr.  Pea- 
cock, its  Aveight  is  about  one-seventh  or  one-eighth  that  of  the 
entire  system,  the  proportions  varying  somewhat  in  diflerent  cases. 

The  brain  does  not  attain  its  full  size,  as  stated  by  Dr.  West,  at 

*  the  age  of  seven  years,  but,  according  to  Dr.  Peacock's  statistics,  it 

continues  to  increase  till  the  age  of  twenty-five  or  thirty,  although 

its  growth  is  less  rapid  after  the  age  of  seven  years  than  previously. 

The  membranous  covering  of  the  cerebro-spinal  axis  is  scarcely 
less  interesting  to  the  pathologist  than  the  axis  itself.  I  shall 
speak  in  the  following  pages  of  the  arachnoid  and  cavity  of  the 
arachnoid,  for  convenience  of  description,  although  aware  of  the 
fact  that  some  eminent  authorities,  as  Vircliow  and  Kdlliker,  whose 
opinions  in  reference  to  the  minute  anatomy  of  the  system  always 
command  attention,  if  not  assent,  believe  that  there  is  no  arach- 
noid, but  what  has  heretofore  been  called  by  this  name  is  on  the 
one  side  the  smooth  surface  of  the  dura  mater,  and  on  the  other  of 
the  pia  mater. 

The  dura  mater  is  seldom  involved  in  the  diseases  of  early  life, 
except  as  it  is  aflected  by  pressure,  while  the  pia  mater  and  arach- 
noid are  the  seat  and  source  of  some  of  the  most  important  diseases, 
as  meningitis,  meningeal  apoplexy,  etc. 

The  more  complicated  and  delicate  the  structure  of  an  organ, 
the  more  liable  it  is  to  errors  of  nutrition  and  o-rowth.  There  is, 
therefore,  no  organ  which  is  so  liable  to  irregular  development  as 
the  brain.  It  may  be  entirely  wanting ;  or  it  may  be  partially 
developed, certain  portions  being  absent;  or,  lastly, its  growth  may 
be  excessive,  constituting  a  true  hypertrophy. 


293 


ACEPHALUS  —  ANENCEPHALUS. 


CHAPTER  I. 


ACEPHALUS— ANENCEPHALUS. 


Entire  absence  of  the  encephalon  is  not  common,  but  there  are 
many  cases  of  this  monstrosity  on  record.  In  extreme  cases  the 
head  and  i3art  of  the  neck,  as  well  as  the  brain  and  medulla  oblon- 
gata, are  absent.  When  there  is  great  deficiency,  there  is  often  a 
twin,  the  presence  of  which  has  interfered  with  the  full  develop- 
ment of  the  system.  Sometimes  the  growth  of  other  organs  besides 
the  brain  is  imperfect. 

Anatomical  Character. — In  the  ordinary  form  of  anencephalus, 
the  brain  and  sometimes  the  medulla  are  absent,  with  the  absence 
or  imperfect  development  of  their  membranous  and  osseous  cover- 
ing. The  vault  of  the  cranium  is  absent.  There  is  deficiency  of 
the  frontal,  parietal,  and  occipital  bones,  except  those  portions 
which  are  near  the  base  of  the  cranium.  These  portions  are  very 
thick  and  closely  united,  as  if  there  were  the  usual  amount  of 
osseous  substance,  but  instead  of  expanding  into  the  arch,  it  had 
collected  in  an  irregular  mass  at  the  base  of  the  cranium. 

The  absence  of  the  brain  and  the  cranial  arch  gives  a  remarka- 
ble appearance.    The  eyes  are  prominent,  the  neck  thick  and  short, 

while  the  body  and  limbs  are  ordi- 
narily well  developed.  The  physiog- 
nomy has  been  compared  to  that  of 
some  of  the  lower  animals. 

Tlie  base  of  the  cranium  is  often 
occupied  by  a   vascular  tumor,  not 
larsce,  but  of  different  size  in  differ- 
ent  cases,  and  continuous  below  with 
the  spinal  pia  mater.     This  vascular 
tumor  is  the   representative   of  the 
cranial  pia  mater,  and  its  smooth  sur- 
face is  the  analogue  of  the  arachnoid. 
The  dura  mater  and  the  scalp  being  absent,  the  exposed  mass  re- 
sembles very  much  in  appearance,  as  it  does  m  structure,  the  pla- 
centa, and  the  sensation  which  it  imparts  to  the  finger  pressed  upon 


IMPERFECT    BRAIN.  299 

it  is  very  similar.  Sometimes  small  portions  of  cerebral  matter 
arc  found  among  the  vessels  of  tliis  tumor,  but  they  are  so  discon- 
nected or  isolated  that  they  do  not  perform,  in  any  way,  the  func- 
tion of  a  brain.  Occasionally  the  vascular  tumor  is  absent,  and  the 
medulla  or  upper  extremity  of  the  spine  is  exposed,  or  it  terminates 
in  a  little  papilla  at  the  back  of  the  neck. 

Those  portions  of  the  cranial  nerves  which  lie  external  to  the 
cranium  are  well  developed,  although  the  intra-cranial  parts  may 
be  absent. 

Symptoms. — The  respiration  in  anencephalous  monsters  is  irre- 
gular. They  can  be  made  to  cry,  but  their  cry  is  a  sort  of  sob  or 
hiccup,  and,  occasionally,  they  even  nurse.  The  digestive  function 
is  well  performed,  and  regular  urinary  and  fecal  evacuations  occur. 
There  is  a  tendency  in  anencephalous  monsters  to  convulsions. 
Blowing  upon  them,  and  pressure  upon  the  projecting  medulla,  if 
this  is  present,  frequently  produce  this  effect. 

Prognosis. — Fortunately  these  monsters  are  short-lived.  If  the 
medulla  oblongata,  which  is  essential  to  the  maintenance  of  respi- 
ration, is  absent,  extra-uterine  life  is  impossible.  Stillbirth  is  the 
result.  If  the  medulla  oblongata  is  present,  although  respiration 
and  circulation  are  established,  death  commonly  takes  place  within 
two  or  three  days,  and  almost  always  within  the  first  week.  Con- 
vulsions sooner  or  later  occur,  ending  in  fatal  coma. 


CHAPTER  II. 

IMPERFECT  BRAIN. 

Between  the  absent  and  complete  brain  there  are  various  grades 
of  deficiency.  Parts  of  the  brain  may  be  perfect,  while  other 
portions  are  either  absent  or  imperfectly  formed.  The  deficiency 
is  usually  in  the  superior  parts  of  the  brain,  especially  in  the  hem- 
ispheres of  the  cerebrum,  while  the  base  of  the  organ  is  perfect. 
Both  hemispheres  may  be  absent,  or  one  may  be  absent,  while  the 
other  hemisphere  is  shrivelled  or  rudimentary.  Occasionally  the 
cranium  preserves  its  normal  shape  and  size,  in  consequence  of  an 
increase  in  the  cerebro-spinal  fluid  proportionate  to  the  lack  of 
brain-substance.  The  imperfect  development  is  not  then  apparent 
to  the  observer.     The  rudimentary  hemispheres  in  these  cases  are 


300  IMPERFECT    BRAIN. 

spread  out,  forming  tlie  walls  of  a  sac  inclosing  tlie  liquid.  The 
post-mortem  examination  of  the  following  case  was  made  in  the 
K'urseiy  and  Child's  Hospital,  of  this  city,  in  1862. 

Case. — Female ;  parentage  healthy ;  she  was  plump  and  well  formed 
at  birth,  and  nothing  unusual  was  observed  in  her  condition,  as  she 
nursed  and  throve  like  other  children,  till  she  reached  the  age  when 
there  is,  usually,  the  first  manifestation  of  intelligence.  With  her  there 
was  no  evidence  of  an  intellect,  or  if  any,  it  was  very  indistinct.  She 
nursed,  or  took  food  when  placed  in  her  mouth,  but  apparently  witliout 
relish,  as  if  instinctively.  She  never  reached  her  hands  towards  the 
nurse,  or  towards  plaj^things.  So  indifferent  and  apparently  uncon- 
scious was  she  of  objects  around  her,  that  it  was  thought  for  some  time 
that  she  was  blind.  She  never  smiled,  except  when  her  hands  were 
gently  rubbed  or  shaken ;  and  then  the  smile  seemed  to  be  more  a  reflex 
movement  than  emotional.  The  smile  was  immediately  succeeded  by  a 
fixed  vacant  look.  She  usually  lay  quietly,  with  her  arms  crossed ;  and 
during  the  last  months  of  her  life  she  sometimes  uttered  a  scream,  like 
children  with  cerebral  diseases.  Her  evacuations  were  regular,  and  she 
was  not  subject  to  vomiting,  before  she  was  attacked  with  the  acute  dis- 
ease of  which  she  died.  The  size  of  her  head  was  rather  less  than  usual 
at  her  age,  but  not  less  than  is  often  seen  in  well-formed  children.  The 
forehead  was  small  in  proportion  to  the  rest  of  the  head,  but  the  differ- 
ence was  not  such  as  to  attract  attention.  Fortunately,  the  existence 
of  this  idiot  Avas  terminated  by  an  attack  of  entero-colitis. 

Sectio  Caclav. — The  head  was  measured,  but  the  measurements  were 
lost.  They  did  not  seein  to  differ  materially  from  the  normal  standard. 
The  sutures  were  united,  and  the  fontanelles  nearly,  if  not  quite,  closed. 
The  frontal  bone  la}^  a  little  lower  than  the  plane  of  the  parietal.  The 
meninges  of  the  brain  presented  nearly'  their  normal  appearance,  but 
were  distended  with  transparent  serum.  The  quantity  of  fluid  was  esti- 
mated at  about  two-thirds  of  a  pint,  and  when  it  was  evacuated,  the 
floor  of  the  lateral  ventricles  was  brought  into  view.  There  was  almost 
an  entire  absence  of  that  part  of  the  brain  which  lies  above  the  floor  of 
the  ventricles.  On  close  inspection,  rudimentary  cerebral  hemispheres 
were  found  in  a  thin  layer  forming  a  part  of  the  walls  of  the  sac.  The 
whole  amount  of  brain-substance  above  the  ventricles  did  not  exceed 
the  size  of  a  small  egg.  The  cerebellum,  the  base  of  the  brain,  and 
cranial  nerves  presented  their  usual  appearance.  The  entire  brain,  after 
being  a  few  days  in  diluted  alcohol,  weighed  six  and  a  quarter  ounces. 

In  this  case,  the  fluid  was  only  suflicient  to  compensate  for  the 
deficiency  of  the  brain.  In  other,  and  probably  the  larger  number 
of  cases  of  incomplete  brain,  the  cerebro-spinal  fluid  is  not  mate- 
rially increased.  There  is  then  but  slight  elevation  of  the  frontal 
l)one,  the  forehead  is  low,  or  retreating,  or  even  almost  absent. 
This  is  that  shape  of  head  which  is  universally  regarded  as  char- 
acteristic of  idiocy. 

Symptoms. — The  symptoms  in  cases  of  deficient  brain  relate  to 
the  mind.  If  the  cerebral  hemispheres  are  absent,  there  is  no  in- 
telligence.    The  individual,  as  regards  mental  endowments,  does 


MICKOCEPHALUS  —  ATKOPHY    OF    BRAIN.  301 

not  rise  above  the  instincts  of  the  lower  animals.  If  the  hemi- 
spheres are  partially  developed,  there  is  a  degree  of  intelligence 
proportionate  to  the  amount  of  cerebral  substance  present.  If  the 
deficiency  is  confined  to  one  side,  there  is  no  apparent  lack  of  intel- 
ligence or  mental  capacity,  since,  the  brain  being  a  double  organ, 
one  side  performs  the  function  of  both. 

Prognosis. — The  prognosis  as  regards  life,  in  cases  of  imperfect 
brain,  depends  not  so  much  on  the  amount  of  deficiency  as  the 
exact  seat  of  arrested  growth.  If  only  the  cerebrum  is  partially, 
or  even  entirely  absent,  the  infant  may  live  and  thrive.  But  if 
those  portions  lying  at  the  base  of  the  brain,  which  control  the 
functions  of  animal  life,  are  lacking,  or  are  imperfectly  formed,  life 
is  very  uncertain,  and  probably  short. 

It  is  evident  that  no  therapeutic  treatment  can  remedy  a  con- 
genital deficiencj'.  The  services  of  the  physician  are  not  required. 
The  philanthropic  and  patient  teacher  may  impart  a  degree  of  intel- 
ligence to  the  idiotic,  and  the  instruction  of  these  unfortunates  has 
of  late  years  been  very  successful. 

Microcephalus— Atrophy  of  Brain. 

An  abnormally  small  brain,  or  microcephalus,  as  it  is  termed, 
sometimes  results  from  premature  closing  of  the  sutures  and  fon- 
tanelles.  If  ossification  is  so  rapid  that  the  cranial  bones  are 
firmly  united,  and  are  of  such  thickness  as  to  be  unyielding  at  the 
time  when  the  growth  of  the  brain  is  most  active,  the  full  devel- 
opment of  this  organ  is  necessarily  prevented.  The  brain  is  com- 
pressed, its  convolutions  flattened,  and  the  functions  of  the  organ 
are  imperfectly  performed.  Death,  sooner  or  later,  is  the  common 
result ;  life  ends  in  convulsions  and  coma. 

Again,  the  brain  of  the  child,  when  undergoing  develoj)ment, 
with  the  cranial  bones  sufficiently  yielding,  may  not  only  cease  to 
grow,  but  may  even  diminish  in  size,  in  consequence  of  protracted 
and  exhausting  diseases.  Diminution  in  the  size  of  the  brain  occurs 
especially  after  fevers  and  diarrhoeal  afiections  of  long  standing 
and  attended  with  much  emaciation.  The  waste  of  the  brain 
corresponds  with  the  general  loss  of  flesh.  If  the  cranial  sutures 
are  not  united,  the  occipital  and  sometimes  the  frontal  bones  are 
depressed,  according  to  the  diminished  size  of  the  brain,  and  are 
overlaid  by  the  parietal.  In  foundlings  of  two  or  three  months, 
this  loss  of  brain-substance  is  often  very  striking.  In  infants  of 
this  class  who  have  died  of  protracted  diarrhoea,  it  is  not  unusual 


302  HYPERTROPHY    OF    BRAIN. 

to  observe  the  occipital  bone  not  only  depressed,  but  extending 
one,  two,  or  even  three  lines  underneath  the  parietal. 

If  the  child  with  shrunken  brain,  from  protracted  and  exhaus- 
tive disease,  is  old  enough  to  express  its  thoughts,  it  often  seems 
foolish,  talks  but  little,  and  perhaj)s  says  the  same  thing  over  and 
over  again.  In  one  case  in  my  practice,  a  litle  girl,  having  passed 
through  a  long  course  of  typhus,  persistently  repeated  during  her 
convalescence,  with  a  silly  smile,  the  questions  addressed  to  her. 
This  peculiarity  continued  two  or  three  weeks,  although  her  appe- 
tite was  good,  and  her  restoration  to  health  rapid.  In  another  case 
a  little  boy,  during  convalescence,  was  wont  to  laugh  heartily  at 
the  appearance  of  the  ordinary  articles  of  furniture  in  the  room. 
Both  showed  more  derangement  of  mind  during  convalescence 
than  in  the  midst  of  the  fever.  The  friends  of  such  children  are  in 
a  state  of  great  anxiety  lest  their  minds  are  permanently  impaired, 
but,  as  the  appetite  and  strength  return,  the  nutrition  of  the  brain 
is  re-established,  and  the  mind  regains  its  former  vigor.  In  cases 
of  wasted  brain,  with  cranial  bones  united,  the  deficiency  is  sup- 
plied by  serous  effusion,  which  is  gradually  absorbed  as  the  health 
of  the  patient  is  re-established,  and  the  brain  enlarges.  This  effu- 
sion occurs  not  only  over  the  convexity  of  the  brain,  but  also  at 
its  base,  and  sometimes  in  the  ventricles.  Dr.  "West  states  that  in 
atrophy  of  the  brain,  from  protracted  disease,  its  texture  is  firmer 
than  usual.  I  have  not  noticed  this  in  infants,  but  my  attention 
has  not  been  directed  particularly  to  this  point.  It  is  probable 
that  there  is  some  change  in  the  anatomical  character  of  the  brain, 
aside  from  mere  waste. 

Partial  atrophy  of  the  brain  sometimes,  also,  occurs  from  pri- 
mary disease  located  in  this  organ ;  the  affected  portion  wastes, 
while  the  rest  retains  its  normal  development. 


CHATTER  III. 

HYPERTROPHY  OF  BRAIN. 

In  contrast  with  atrophy  of  the  brain  is  the  opposite  state,  or 
hypertrophy.  The  size  of  this  organ  within  the  limits  of  health 
varies  greatly  in  different  individuals,  but  sometimes  there  is  so 
great  an  increase  in  volume  as  to  properly  constitute  a  disease. 


PATHOLOGICAL    ANATOMY.  303 

Pathological  Anatomy. — The  excess  of  growth  which  charac- 
terizes this  disease  has  heen  ascertained  to  be  confined  to  the  white 
portion  of  the  brain,  and  ordinarily  to  that  part  contained  in  the 
cerebral  hemispheres.  Hypertrophy  of  the  brain  is  attended  by 
induration,  which  exists  in  diftcrent  degrees  in  difibrcnt  cases.  It 
is  in  some  so  slight  as  to  be  scarcely  appreciable ;  while  in  others 
it  IS  apparent  at  once  by  pressure  with  the  finger,  or  incision  with 
the  scalpel.  Rilliet  and  Barthez  state  that  the  induration  in 
some  cases  resembles  in  degree  and  appearance  that  produced  by 
the  action  of  alcohol.  The  white  substance  of  the  cerebrum  is 
not  only  resisting  and  elastic,  but  its  color  is  unusually  pale ;  it 
presents  even  a  brilliant  or  polished  appearance.  At  the  same 
time  the  gray  substance  is  more  or  less  faded,  and  its  depth  in  the 
convolutions  is  less  than  in  the  normal  state  of  the  organ.  Roki- 
tansky  says :  "  The  cineritious  matter  is  generally  of  a  pale  gray- 
ish-red color.  The  medullary  is  always  dazzling  white,  and  remark- 
ably pale  and  anjemic."  An  unusual  case  is  related  by  Burnet,  in 
which  the  gray  substance  in  the  corpora  striata  retained  its  usual 
color,  and  was  indurated  like  the  white  substance.  In  exceptional 
cases  the  cerel^ellum  as  w^ell  as  cerebrum  undergoes  hypertrophy, 
becoming  at  the  same  time  more  or  less  indurated.  In  Burnet's 
case  there  was  induration  of  the  optic  nerves.  "  The  internal  struc- 
ture," he  says,  "  of  the  optic  nerves,  especially  in  their  bulbs,  had 
the  polish,  homogeneous  appearance,  elasticity,  and  almost  the 
hardness  of  cartilage."  Rilliet  and  Barthez  state  that  in  two  cases 
the  spinal  cord  presented  even  more  marked  induration  than  the 
encephalon.  Congestion  is  not  a  feature  of  hypertrophy.  On  the 
other  hand,  there  is  often  less  vascularity  of  the  brain  and  its 
membranes  than  in  the  healthy  state.  If  the  cranial  bones  are 
completely  ossified  at  the  time  when  hypertrophy  commences,  and 
firmly  united,  enlargement  of  the  brain  is  partially  prevented. 
The  convolutions  are  then  thin,  much  flattened,  the  sulci  more  or 
less  efiaced,  the  membranes  pale  and  dry,  and  the  ventricles  are 
small  and  nearly  destitute  of  serum.  At  the  autopsy  of  such  a 
case,  when  the  dura  mater  is  incised,,  the  expansion  of  the  brain 
prevents  the  proper  refitting  of  the  skullcap.  Occasionally  hyper- 
trophy causes  more  or  less  absorption  of  the  cranium,  and  perhaps 
the  sutures  already  united  are  pressed  apart. 

If  hyj)ertrophy  commences  in  young  infants  with  the  fontanelles 
and  sutures  still  open,  they  usually  remain  open,  or  are  a  long  time 
in  uniting.  The  interspaces  continue,  not  only  in  consequence  of 
the  growth  of  the  brain,  which  tends  to  separate  the  bones,  but 


304  HYPEETROPHY    OF    BRAIN. 

also  in  consequence  of  feeble  ossification.     The  shape  of  the  head  . 
arrests  attention.    Hypertrophy  usually  produces  most  enlargement 
between  and  above  the  ears,  while  the  frontal  portion  of  the  head, 
though  somewhat  enlarged,  is  less  developed. 

The  direction  of  the  eyes  is  not  changed,  as  is  common  in  con- 
genital hydrocephalus. 

Rokitansky  says  (vol.  iii.  page  285):  "With  regard  to  the 
question  to  be  decided  by  the  theory  and  microscopic  examination, 
as  to  the  nature  of  the  added  material  upon  which  the  increase  of 
volume  depends,  I  have  formed  the  following  opinion  from  repeated 
investigations : — • 

"1.  The  disease  is  genuine  hypertrophy. 

"2.  It  consists,  as  such,  not  in  an  increase  in  the  number  of 
nerve-tubes  in  the  brain,  from  new  ones  being  formed,  nor  in  an 
increase  in  the  dimensions  of  those  which  already  exist,  either  as 
thickening  of  their  sheaths,  or  as  augmentation  of  their  contents, 
by  either  of  which  the  nerve-tubes  would  become  more  bulky ; 
but, 

"  3.  It  is  an  excessive  accumulation  of  the  intervening  and  con- 
necting; nucleated  substance." 

It  is  now  generally  admitted  that  the  views  of  Rokitansky  are 
correct,  that  hypertrophy  of  the  brain  is  due  to  an  augmentation 
in  the  amount  of  connective  tissue,  which  lies  between  and  unites 
the  tubules. 

Causes. — Hypertrophy  of  the  brain  is  commonly  associated  with 
rachitis  or  scrofula,  or  some  error  in  the  nutritive  process,  which 
shows  itself  in  other  parts  of  the  system  as  well  as  the  brain. 
Rilliet  and  Barthez  consider  frequent  congestion  of  the  brain  as  a 
common  cause  of  hypertrophy.  This  disease  is  not  common  in 
this  country.  It  is  most  frequently  met  in  hospitals  for  children, 
and  among  the  poor  of  the  cities,  whose  systems  are  rendered 
cachectic  by  residence  in  damp  and  dark  localities,  and  by  unwhole- 
some diet.  In  the  deep  valleys  of  Switzerland,  and  in  parts  of 
South  America  and  Asia,  hypertrophy  of  the  brain  is  common, 
under  the  name  cretinism.  It  is  associated  with  rachitis  and 
stunted  growth.  The  abnormal  development  which  occurs  in  cre- 
tinism begins  in  infancy  or  early  childhood,  and  the  unfortunate 
subjects  of  it  are  short-lived.  Cretinism  has  been  attributed  to  a 
residence  in  localities  wet  and  deprived  in  great  measure  of  solar 
light,  and  to  general  disregard  of  the  laws  of  health  on  the  part 
of  those  affected  as  well  as  their  parents.  A  recent  thorough 
examination  of  the  subject  lends  support  to  the  view  that  it  is 


SYMPTOMS.  305 

caused  by  the  use  of  water  containing  one  of  the  combinations  of 
vsuljiliiir  and  iron. 

The  observations  of  different  pliysicians  also  establish  a  connec- 
tion between  some  cases  of  hypertrophy  and  the  saturation  of 
the  system  by  lead.  In  what  way  lead-poisoning  leads  to  hyper- 
trophy is  obscure,  but  the  concurrent  testimony  of  different  ob- 
servers is  so  strong,  that  we  cannot  doubt  that  it  does  sometimes 
have  that  effect. 

Symptoms. — The  symptoms,  as  is  the  case  with  most  organic 
diseases  of  the  brain,  vary  considerably  in  different  cases.  Some- 
times there  is,  at  tirst,  more  or  less  depression  or  languor.  If  the 
child  is  old  enough  to  speak,  he  may  complain  of  pain  in  the 
abdomen  or  limbs,  evidently  neuralgic,  or  of  headache.  After  a 
variable  time  vomiting  succeeds,  and  finally  convulsions,  affecting 
the  muscles  of  the  face,  as  well  as  extremities ;  the  convulsions 
are  usually  clonic,  but  sometimes,  as  regards  at  least  the  extremi- 
ties, of  a  tonic  character.  The  pupils  may  be  contracted  or  dilated ; 
there  is  restlessness  alternating  with  drowsiness,  and  finally  coma 
succeeds. 

Hypertrophy  may  continue  a  considerable  time  before  serious 
symptoms  arise ;  but  when  once  developed,  these  symptoms  ordi- 
narily continue  with  more  or  less  severity  till  death.  Death 
commonly  results  within  a  week  after  their  commencement,  but 
sometimes  not  till  several  weeks  have  elapsed.  When  death  oc- 
curs at  an  early  period  in  the  disease,  there  is  usually  firm  ossifi- 
cation and  union  of  the  cranial  bones,  and,  therefore,  but  moderate 
enlargement  of  the  cranium. 

If  hypertrophy  commences  at  a  period  not  far  removed  from 
l)irth,  the  bones,  of  course,  yield  more  readily  to  the  pressure,  and 
acute  symptoms  do  not  occur  so  soon.  After  a  time,  however,  in 
all  or  nearly  all  cases,  convulsions  supervene.  These  indicate  the 
gravity  of  the  disease,  and  are  prognostic  of  its  fatal  termination. 

In  a  patient  observed  by  Burnet,  violent  convulsions,  followed 
by  loss  of  consciousness,  marked  the  commencement  of  acute  symp- 
toms. Five  days  subsequently,  the  following  symptoms  were 
recorded:  mobility  of  the  eyes,  without  expression;  pupils  con- 
tracted, and  directed  upwards;  divergent  strabismus  of  the  left 
eye ;  the  senses  in  their  normal  state,  with  the  exception  of  sight ; 
the  limbs  move  by  volition.  For  a  month  there  was  little  change. 
Then  occurred  drowsiness,  and  increased  prostration,  and  five 
weeks  later  the  child  succumbed  with  the  symptoms  of  double 
pneumonia. 
20 


306  HYPERTROPHY    OF    BRAIN. 

Such  is  the  clinical  history  of  hypertrophy.  In  cases  of  firm 
ossification  of  the  cranial  bones,  and,  therefore,  no  marked  enlarge- 
ment of  the  skull,  the  symptoms  are  similar  to  those  which  occur 
if  the  dimensions  of  the  head  are  increased,  only  compression  and 
death  result  sooner. 

The  following  case,  in  which  the  sutures  were  firmly  united,  I 
attended  in  1864.  The  head  was  large,  but  not  so  large  as  to 
attract  attention  from  its  disproportion. 

Case. — A  boy,  aged  two  years  and  two  months,  had,  when  about  one 
year  old,  fever  and  ague,  and  since  then  his  countenance  was  uniformly 
l^aliid,  and  his  flesh  soft.  Weaned  at  the  usual  time,  he  remained  well 
till  the  first  of  January,  1864.  In  the  beginning  of  this  month  he  was 
observed  to  be  feverish  for  some  days,  and  his  appetite  poor.  His  health 
then  graduall}'-  improved,  and  he  was  thought  to  be  entirely  well. 

On  the  26th  of  February  he  was  suddenly  seized  with  convulsions, 
general  at  first,  but  most  severe  and  continuing  longest  on  the  left  side. 
The  convulsions  lasted  a  little  more  than  three  hours.  He  recovered 
fuU}^  his  consciousness  by  the  following  daj^,  but  his  appetite  remained 
poor;  he  was  no  longer  amused  bj'  his  pla3'things,  and  was  very  fretful. 
The  surface  was  pallid;  bowels  constipated;  pulse  but  little,  perhaps 
not  at  all,  accelerated.  He  continued  in  this  state  till  the  6th  of  March, 
when  he  had  another  slight  convulsive  attack,  and  from  this  time  he 
never  fully  recovered  his  consciousness.  He  was  fretful  if  disturbed, 
his  face  generall}^  pallid,  while  the  pulse  and  respiration  were  not  per- 
ceptibly altered. 

On  the  following  day,  the  Vth,  the  left  pupil  was  somewhat  larger 
than  the  right,  but  both  were  sensitive  to  light.  The  difference  in  size 
continued  till  near  the  close  of  life.  Although  vision  was  imperfect,  if 
not  altogether  lost,  the  sense  of  hearing  was  not  impaired. 

When  questioned,  he  uniformly  answered  "No,"  with  a  drawling 
voice,  evidently  not  understanding  what  he  said. 

As  the  disease  advanced,  the  respiration  became  at  times  sighing;  but 
the  rhythm  of  the  pulse  was  not  materially  altered.  The  temperature 
of  the  surface  was  changeable,  sometimes  cool,  sometimes  warm,  and 
the  congested  spots  or  patches,  so  common  in  cerebral  affections,  were 
also  observed  at  times  on  the  face,  ears,  or  forehead.  Througli  most 
of  his  sickness,  he  took  drinks  readily,  and  the  urine  was  freely  dis- 
charged, probably  from  the  iodide  of  potassium,  which  he  took  in  one 
and  a  half  grain  doses  every  two  hours. 

He  became  more  and  more  drowsy,  again  had  slight  convulsive  move- 
ments, and  finally  died,  with  much  apparent  suffering,  on  the  14th  of 
March.  The  pulse  became  more  accelerated  during  the  last  two  or  three 
days.  On  the  day  preceding  his  death,  the  pupils  were  contracted,  and 
not  affected  b}'  the  light. 

Sectio  Cadav. — Body  somewhat  emaciated,  and  eyes  sunken;  occipito- 
frontal circumference  of  head  nineteen  and  a  half  iiiches ;  distance  from 
one  auditory  meatus  to  the  other  over  the  vertex,  thirteen  and  a  half 
inches;  convolutions  over  the  surface  of  the  brain  much  flattened  and 
compressed;  brain  generally  deficient  in  blood;  medullar}'-  substance 
firm,  and  of  a  pure  white  color;  meninges  healthy;  no  other  abnormal 
appearances  were  observed;  weight  of  brain  forty-two  ounces. 


DIAGNOSIS  —  PROGNOSIS.  307 

Diagnosis. — Tlie  diagnosis  of  hypertrophy  is  not  always  easy. 
The  symptoms  are,  in  tlic  main,  such  as  occur  in  other  pathological 
states,  especially  congenital  hydrocephalus.  There  is  most  danger 
of  mistaking  the  overgrowth  for  this  disease.  Hypertrophy  has, 
indeed,  often  been  treated  for  hydrocephalus.  There  are,  however, 
certain  signs  by  which  we  may  distinguish  one  from  the  other. 
In  the  ordinary  form  of  congenital  hydrocephalus,  even  when  the 
amount  of  liquid  is  small,  the  orbital  plates  of  the  frontal  bones 
are  pressed  in  such  a  way  that  the  axis  of  the  eyes  is  changed  so 
as  to  have  a  downward  direction.  The  white  of  the  eye  can  be 
seen  between  the  iris  and  the  upper  eyelid.  This  gives  a  charac- 
teristic and  striking  expression  to  the  face.  The  exception  to  this 
is  in  those  rare  cases  in  which  the  liquid  is  external  to  the  brain. 
In  hypertrophy  this  peculiar  change  in  the  axis  of  the  eyes  does  not 
occur.  Moreover,  in  hyjoertrophy  there  is  not  that  uniform  expan- 
sion of  the  head  which  is  observed  in  hydrocephalus,  as  has  been 
stated  above.  There  are,  commonly,  greater  enlargement,  more 
prominence  of  the  anterior  fontanelle,  and  wider  separation  of  the 
cranial  bones,  in  hydrocephalus  than  in  hypertrophy. 

Hypertrophy  with  consolidation  of  the  cranial  bones,  and, 
therefore,  little  enlargement  of  the  head,  may  be  mistaken  for 
meningitis.  The  history  of  the  case,  and  the  means  by  which  we 
diagnosticate  the  latter  afiection,  which  will  be  described  in  their 
proper  place,  will  usually  enable  the  physician  to  make  a  correct 
diagnosis. 

Prognosis. — In  forming  an  opinion  as  to  the  probable  termination 
of  the  disease,  we  must  have  regard  to  the  age  and  general  condi- 
tion of  the  child,  as  well  as  to  the  degree  of  hypertrophy.  If  the 
disease  commence  at  an  early  age,  when  the  cranial  bones  are  not 
firmly  united,  it  is  probable  that  there  will  be  no  compression  of 
the  brain,  so  as  to  endanger  life,  for  a  considerable  period.  "We 
may  then  hope  by  proper  measures  to  remove  the  constitutional 
state  which  gives  rise  to  the  hypertrophy,  before  the  enlargement 
is  such  as  to  cause  cerebral  symptoms.  If  the  bones  have  already 
united  when  the  disease  commences,  even  slight  hypertrophy  will 
produce  symptoms,  and  a  speedily  fatal  result  is  inevitable.  Evi- 
dently, also,  a  child  in  a  marked  degree  rachitic  or  scrofulous  is 
much  less  likely  to  recover  than  one  whose  general  health  and 
constitution  are  less  impaired. 

Treatment. — The  treatment  in  hypertrophy  should  be  directed 
mainly  to  the  constitution.  Measures  calculated  to  improve  the 
nutritive  process   are  those   most   likely  to  check  the  abnormal 


308  THROMBOSIS    IX    THE    CRAXIAL    SINUSES. 

growth  of  the  brain.    As  the  disease  is  one  of  perverted  nutrition, 

and  usually  coexists  with  a  vitiated  or  impoverished  state  of  the 

blood,  tonic   and    alterative   remedies   are  required.     The  liquor 

ferri  iodidi  is,  therefore,  useful,  as  it  is  both  tonic  and  alterative. 

This  may  be  given  in  doses  of  three  or  four  drops  to  a  child  one 

year  old,  three  times  daily.     Cod-liver  oil,  with  or  without  the 

iron,  is  beneficial  in  some  cases.     Another  remedy  is  iodide  of 

potassium  in  <;ombination  with  a  tonic,  as  the  compound  tincture 

of  bark. 

^.  Potas.  iodid.  3j  ; 

Tinct.  cincbon  comp., 
Syr.  limonum,  aa  §ij.    Misce. 
One  teaspoonful,  three  times  daily,  to  a  child  of  three  years. 

The  hygienic  treatment  is  not  less  important  than  the  medicinal. 
There  is  little  hope  of  a  favorable  issue  in  any  case,  unless  the 
regimen  is  such  as  will  conduce  to  a  more  robust  and  healthy 
state  of  system.  The  diet  should  be  plain  and  nutritious,  the 
apartments  clean  and  airy,  and  all  undue  excitement  should  be 
avoided. 


CHAPTER  IV, 

THROMBOSIS  IN  THE  CRANIAL  SINUSES  (PHLEBITIS). 

The  formation  of  fibrinous  coagula  within  a  vein  or  sinus  is 
designated  thrombosis  {thrombus,  clot).  Coagulation  of  fibrin  in 
the  cranial  sinuses  occasionally  occurs,  constituting  a  very  serious 
pathological  state.  This  may  result  from  local  disease  in  the 
sinuses  or  in  their  vicinitv,  or  from  disease  external  to  the  cranium. 
The  immediate  cause  of  thrombosis,  whatever  its  location,  is  suffi- 
cient arrest  of  the  circulation  to  allow  the  fibrin  to  coagulate.  _ 

Tubercular  and  enlarged  bronchial  glands,  compressing  more  or 
less  the  ven?e  innominatse  or  the  descending  vena  cava,  sometimes 
give  rise  to  thrombosis  in  the  cranial  sinuses,  the  fibrin  coagulating 
in  consequence  of  retardation  in  the  current  of  blood.  I  have 
known  thrombosis,  in  the  same  situation,  also  to  result  from  clonic 
convulsions,  occurring  in  connection  with  severe  spasmodic  cough 
in  pertussis,  since  both  the  cough  and  convulsions  retard  the  flow 
of  blood  in  the  veins  and  sinuses  within  the  cranium.     At  the 


ANATOMICAL    CHARACTERS.  309 

post-mortem  examination  of  two  sucli  cases  I  found  firm  whitish 
clots  in  the  lateral  sinuses. 

Thrombosis,  in  the  cranial  sinuses,  may  also  occur  from  inflam- 
mation either  in  the  walls  of  the  sinuses,  or  immediately  exterior 
to  them.  This  is  the  disease  which  writers  have  designated 
phlebitis  of  the  cranial  sinuses,  and  for  a  correct  understanding 
of  the  morbid  anatomy  of  which  the  profession  are  indebted  to 
Virchow. 

Anatomical  Characters. — If  a  child  die  with  the  cranial 
sinuses  and  the  veins  of  the  brain  and  of  the  meninges  in  their 
normal  state,  the  blood  in  these  vessels  is  found  at  the  autopsy 
dark  but  liquid,  or  there  are  small,  dark,  and  soft  clots  in  the  larger 
sinuses.  If  there  was  congestion,  but  no  coagulation,  in  these 
vessels  in  the  last  hours  of  life,  the  clots  are  more  numerous, 
larger,  and  longer,  sometimes  extending  from  the  sinuses  into  the 
larger  veins  which  empty  into  them,  but  they  are  still  dark  and 
soft,  readily  falling  to  pieces  when  handled.  If,  again,  there  has 
been  that  degree  of  congestion  and  stasis  which  has  resulted  in 
ante-mortem  coagulation,  or  in  thrombosis,  the  clots  are,  in  part  at 
least,  whitish,  and  of  a  fibrinous  or  gelatinous  appearance ;  they 
were  formed  while  the  red  corpuscles  were  still  carried  along  in  the 
circulation. 

Most  of  the  clots  in  thrombosis  are  free,  while  others  are  at- 
tached lightly  to  the  internal  surface  of  the  sinus ;  occasionally 
they  are  so  large  as  to  distend  the  vessel.  They  extend  also  in 
many  cases  into  the  cerebral  veins  which  connect  with  the  sinuses, 
producing  prominence  and  firmness,  so  as  to  resemble  (Rilliet  and 
Barthez)  an  artificial  injection.  The  clots  do  not  present  a  uniform 
character.  In  parts  of  a  sinus  they  consist  of  almost  pure  fibrin, 
of  a  yellowish- white  color,  while  in  other  portions  they  present  a 
gelatinous  appearance  from  the  large  number  of  white  corpuscles, 
while  other  portions  are  more  or  less  tinged  from  the  presence  of  red 
corpuscles.  The  central  part  of  the  clot,  after  a  time,  if  the  case  is 
sufficiently  protracted,  softens,  and  presents  a  puriform  appearance. 
This  substance,  which  is  only  disintegrated  fibrin,  was  supjwsed 
to  be  pus,  till  the  microscope  revealed  its  true  character.  It  is 
obvious  that  small  clots  forming  within  a  sinus,  and  having  no 
attachment  to  its  walls,  are  liable  to  be  carried  by  the  current  of 
blood  into  the  general  circulation,  unless  there  is  complete  obstruc- 
tion. Virchow  has  also  shown  how  a  thrombus  may  extend,  by 
gradual  prolongation,  nearer  and  nearer  the  heart,  so  that  one 
commencing  in  a  sinus  may,  after  a  time,  reach  into  the  jugular 


3i0  THEOMBOSIS    IN    THE    CRANIAL    SINUSES. 

vein.  Different  observers,  as  M.  Tonneld,  and  also  Rilliet  and 
Barthez,  have  traced  the  fibrinous  masses  as  far  as  the  cava.  The 
latter  writers  relate  the  case  of  a  girl,  four  and  a  half  years  old, 
in  whom  the  sinuses  on  the  left  side,  especially  those  nearest  the 
petrous  portion  of  the  temporal  bone,  were  completely  filled  with 
clots  of  a  yellowish-white  color,  intermixed  with  central  dark 
spots.  Similar  coagula  were  also  found  in  the  left  jugular  vein  as 
far  as  the  brachio-cephalic  trunk.  "Whether  the  walls  of  the  sinus 
undergo  any  change  depends  on  the  nature  of  the  disease  which 
causes  the  thrombosis.  If  it  be  phlebitis,  the  coats  are  thickened 
from  infiltration  and  injected,  and  the  internal  coat  has  lost  its 
polish.  If  it  be  some  obstructive  disease  in  the  course  of  the 
circulation,  or  a  general  cause,  the  coats  of  the  vessel  are  unaltered, 
except  that  they  may  be  stained  by  imbibition  of  the  coloring 
matter  of  the  blood.  In  an  infant  who  died  of  this  disease  in  the 
practice  of  Dr.  West,  "the  sinuses  on  the  left  side  were  healthy, 
but  the  blood  was  almost  entirely  coagulated.  The  posterior  half 
of  the  longitudinal  sinus,  the  torcular,  the  left  lateral,  and  the  left 
occipital  sinuses,  were  blocked  up  with  fibrinous  coagulum,  pre- 
ciselv  such  as  one  sees  in  inflamed  veins,  and  the  clot  extended  into 
the  internal  jugular  vein.  The  coats  of  the  longitudinal,  and  of 
the  inner  half  of  the  lateral  sinus,  were  much  thickened,  and  their 
lining  membrane  had  lost  its  polish,  was  uneven,  and  presented  a 
dirty  appearance." 

The  mode  in  which  congestion  and  coagulation  occur  within  a 
sinus,  in  consequence  of  the  pressure  of  a  tumor  upon  this  vessel, 
or  upon  a  vein  into  which  the  blood  from  this  sinus  flows,  is  suffi- 
ciently obvious.  The  mode  of  the  production  of  thrombosis,  as  a 
result  of  clonic  convulsions,  or  of  the  spasmodic  cough  of  pertussis, 
is  also  apparent.  How  it  results  from  inflammation  of  the  walls 
of  a  sinus,  that  is,  from  phlebitis,  was  not  understood  till  explained 
by  Virchow. 

The  fibrinous  coagula  which  fill  the  sinus  are  not  an  exudative 
product,  as  was  formerly  supposed.  Inflammation  (in  most  cases 
otitis,  with  caries  of  the  petrous  portion  of  the  temporal  bone) 
approaches  a  sinus.  The  inflammatory  products  pressing  against 
the  walls  of  the  sinus  diminish  its  calibre  at  that  point,  and  hence 
the  retardation  of  the  current  of  blood  and  the  coagulation.  Or 
the  walls  of  the  sinus  may  be  thickened  by  inflammatory  infiltra- 
tion, or  even  by  the  formation  of  little  abscesses  within  the  coats 
in  consequence  of  the  inflammation,  so  as  to  produce  bulging 
inwards,  and  the  result,  as  regards  the  circulation,  is  the  same. 


CAUSES.  311 

Whether,  therefore,  tlie  inflammation  occur  without  a  sinus,  or 
within  its  walls,  thrombosis  equally  results,  provided  that  the 
diameter  of  the  vessel  is  sufficiently  narrowed  by  the  presence  and 
pressure  of  inflammatory  products. 

There  is  no  exudation  on  the  internal  surface  of  a  sinus  or  vein 
when  inflamed,  as  there  is  upon  serous  surfaces.  "On  the  con- 
trary" {Cellular  P«<Ao^o_j7_y,  translation,  p.  236),  "when  the  wall  is 
inflamed,  the  exuded  matter  (exsudatmasse)  passes  into  the  wall, 
which  becomes  thicker,  cloudy,  and  subsequently  begins  to  sup- 
purate. N^ay,  even  abscesses  may  form  which  cause  the  wall  to 
bulge  on  both  sides  like  a  variolous  pustule,  without  any  coagula- 
tion of  the  blood  ensuing  in  the  cavity  of  the  vessel.  At  other 
times,  certainly,  phlebitis,  properly  so  called  (and  in  like  manner 
arteritis  and  endocarditis),  is  the  cause  of  thrombosis,  in  conse- 
quence of  the  formation  of  inequalities,  elevations,  depressions,  and 
even  ulcerations  upon  the  inner  wall  which  favor  the  production 
of  the  thrombus.  Still,  whenever  phlebitis,  in  the  usual  sense  of 
the  word,  takes  place,  the  alteration  in  the  coat  of  the  vessel  is 
almost  always  a  secondary  one,  and,  indeed,  occurs  at  a  compara- 
tively late  period." 

This  view  of  the  pathology  of  thrombosis  comports  with  facts 
observed  at  autojisies,  and  which  cannot  be  explained  according  to 
the  old  theory  of  phlebitis,  namely,  smoothness  of  the  internal 
surface  of  the  sinus ;  natural  color  of  this  sinus,  or  simple  stain- 
ing from  blood ;  the  non-attachment  or  slight  attachment  of  the 
coagula,  etc. 

Causes. — Some  of  these  have  been  already  stated  at  the  com- 
mencement of  this  article.  It  is  evident  from  what  has  been  said 
that  this  disease  may  be  produced  by  any  cause  which  obstructs 
the  return  circulation  from  the  head.  I  have  already  alluded  to 
tumors  which  press  upon  the  sinus,  or  on  the  vein  below  the  sinus, 
as  a  cause.  Amono;  the  causes  mav  be  mentioned  also  abdominal 
tumors,  narrowing  of  the  chest  from  rachitis,  or  caries  of  the  ver- 
tebrse,  and,  finally,  compression  of  the  jugular  vein  by  a  retro- 
pharyngeal abscess. 

Sufficient  allusion  has  already  been  made  to  inflammation  of  the 
internal  ear  as  a  not  infrequent  cause.  Thrombosis  is,  indeed,  the 
most  dangerous  result  of  chronic  otitis.  Another  cause  is  a  re- 
duced or  cachectic  state  of  system,  apart  from  any  local  obstructive 
disease.  It  is  a  noteworthy  fact  that  a  large  proportion  of  those 
afiected  with  thrombosis,  even  when  it  is  immediatelj'-  due  to  ob- 
structive disease,  are  cachectic.     The  explanation  of  this  fact  is 


312  THROMBOSIS    IN    THE    CRANIAL    SINUSES. 

not  difficult.  In  reduced  states  of  the  system  the  action  of  the 
heart  is  feeble,  and  passive  congestion  of  the  vessels  within  the 
cranium  is  apt  to  occur.  Passive  congestion  of  the  veins  and 
sinuses  in  protracted  diarrhoeal  maladies,  which  is  described  in  our 
remarks  upon  another  disease,  is  an  example  in  point.  In  this 
state  of  feeble  circulation  very  slight  obstructive  disease  may  be 
sufficient  to  cause  thrombosis. 

Symptoms. — The  symptoms  of  this  disease  are  often  obscure. 
All  of  them  may  and  do  occur  in  other  diseases  of  the  encephalon. 
In  cases  related  by  M.  TonneM,  cerebral  symptoms  were  well 
marked,  such  as  faintness,  dilation  of  the  pupils,  strabismus,  grind- 
ing the  teeth,  convulsive  movements.  There  may  be  an  almost 
total  absence  of  such  symptoms  as  would  direct  attention  to  the 
state  of  the  head.  This  is  due  to  the  sudden  occurrence  of  death 
in  such  cases  after  the  clots  have  formed.  If  the  clots  are  large, 
death  soon  results  in  consequence  of  congestion  of  the  brain  and 
meninges,  which  is  proportionate  to  the  amount  of  obstruction. 
Extravasations  of  blood  and  transudation  of  serum  not  infrequently 
accompany  the  congestion  and  hasten  the  result. 

Dr.  West  relates  the  case  of  a  girl  who  had  a  mild  attack  of 
scarlet  fever  at  the  age  of  eight  months,  and  did  not  fully  recover 
her  health.  She  continued  restless  and  feverish,  and  had  two  vio- 
lent convulsions  two  weeks  after  the  scarlatina.  In  the  following 
months  she  had  anasarca,  and  when  she  was  nearly  a  year  old 
another  attack  of  convulsions  occurred.  Fluctuation  was  now 
observed  in  the  abdomen,  and  in  a  few  days  a  sero-purulent  fluid 
began  to  escape  from  the  umbilicus.  When  this  discharge  had 
continued  eleven  days,  symptoms  of  a  liquid  in  the  right  pleural 
cavity  were  suddenly  developed.  She  grew  weak  and  emaciated, 
and  finally  was  seized  with  extreme  faintness,  with  which  she  died 
in  forty-eight  hours,  at  the  age  of  thirteen  and  a  half  months. 

At  the  post-mortem  examination  a  large  amount  of  pus  was 
found  in  the  abdominal  and  right  pleural  cavities.  On  the  right 
side  of  the  cranium  the  sinuses,  were  filled  with  coagula,  and  their 
coats  seemed  healthy.  The  left  lateral  and  occipital  sinuses,  the 
torcular  and  part  of  the  longitudinal  sinus,  also  contained  coagula, 
which  extended  into  the  jugular  vein.  The  walls  of  the  longitu- 
dinal sinus  and  the  internal  part  of  the  lateral  sinus  were  thick- 
ened, and  their  inner  surface  had  lost  its  polish  and  was  uneven. 
There  was  congestion  of  the  brain,  with  points  of  extra vasated 
blood.  If,  as  is  probable,  the  convulsions  were  due  to  some  other 
cause,  the  only  symptom  which  was  clearly  referable  to  the  throm- 


DIAGNOSIS  —  I'ROGNOSIS  —  TREATMENT.  313 

bosis  was  the  sudden  faintncss.  In  the  two  cases  of  thrombosis 
occurring  in  pertussis,  ah^eady  alluded  to,  and  in  which  I  was  en- 
abled to  ascertain  by  post-mortem  examination  the  presence  and  ex- 
tent of  the  clots,  the  symptoms,  which  were  apparently  due  to  the 
thrombosis,  were  those  of  cerebral  congestion.  Among  these  symp- 
toms, stupor,  and  finally  coma,  were  prominent.  The  convulsions 
which  occurred  in  both  cases  were  apparently  a  cause,  and  not  result, 
of  the  thrombosis. 

Diagnosis. — It  is  evident,  from  what  has  been  said,  that  throm- 
bosis of  the  cranial  sinuses  can  rarely  be  diagnosticated  with 
certainty.  The  pre-existence  of  otitis  will  sometimes  lead  us  to 
suspect  its  presence,  especially  if  the  otitis  has  been  accompanied 
by  deep-seated  pains.  Symptoms  of  cerebral  congestion,  serous 
effusion,  or  ajwplexy,  occurring  in  connection  with  otitis,  pro- 
tracted convulsions,  or  glandular  or  other  tumors  situated  so  as  to 
compress  the  vessels  which  return  blood  from  the  brain,  indicate 
thrombosis. 

Prognosis. — The  prognosis,  in  any  case,  is  obviously  unfavorable. 
The  cause  is,  ordinarily,  permanent,  or  not  readily  removed,  so  that 
the  clots  gradually  increase.  If  the  cause  is  local  obstructive  dis- 
ease, death  is  almost  certain,  since,  in  nearly  every  instance,  the 
obstruction  is  of  such  a  nature  that  it  cannot  be  removed  by  medical 
or  surgical  treatment.  It  is  possible  that  recovery  may  take  place 
if  the  clots  are  few  and  small,  and  the  cause  of  the  thrombosis  is 
mainly  feebleness  of  circulation  in  consequence  of  a  state  of  debility. 
We  know  that  clots  may  liquefy,  and  their  elements  re-enter  the 
circulation ;  but  such  a  result  of  thrombosis  in  a  cranial  sinus,  if 
it  ever  occurs,  is  rare.  The  thrombus,  by  its  presence,  serves  as  a 
point  of  attachment  around  which  more  fibrin  coagulates,  so  that 
the  obstruction  gradually  increases  till  death  occurs. 

Treatment. — Thrombosis  should  be  treated  by  cool  applications 
to  the  head,  in  order  to  diminish  the  congestion,  by  stimulants  and 
sustaining  measures  in  case  the  systolic  movement  of  the  heart  is 
feeble.  Tonics,  vegetable  or  ferruginous,  are  indicated  if  there  is 
a  cachectic  state. 


314  CONGESTION    OF    BRAIN. 


CHAPTER  Y. 

CONGESTION  OF  BRAIN. 

Congestion  of  the  brain  is  not  peculiar  to  infancy  and  childhood, 
but  is  much  more  common  in  these  periods  of  life  than  subse- 
quently. This  is  due,  in  a  great  measure,  to  the  fact  that  in  the 
young  the  circulation  is  more  readily  disturbed  by  moral  as  well 
as  physical  causes  than  in  the  adult. 

Congestion  of  the  brain  is  occasionally  primary;  more  fre- 
quently it  occurs  as  a  concomitant  or  sequel  of  some  other  affection. 
Diseases,  whether  constitutional  or  local,  which  in  the  adult  have 
no  appreciable  effect  on  the  vascularity  of  the  brain,  often  cause 
in  the  child  a  decided  increase  of  blood  in  this  organ. 

Causes. — Cerebral  congestion  is  of  two  kinds,  active  and  pas- 
sive. The  former  results  from  a  cause  which  directly  affects  the 
brain,  and  increases  the  flow  of  blood  towards  it,  or  from  a  cause 
operating  primarily  on  the  heart,  and  increasing  the  frequency 
and  force  of  its  systolic  movement ;  the  latter  is  due  to  some 
obstruction  in  the  course  of  the  circulation,  or  to  a  feeble  pro- 
pelling power  on  the  part  of  the  heart. 

Among  the  causes  which  most  frequently  produce  active  con- 
gestion of  the  brain  in  the  child,  may  be  mentioned  blows  or  falls 
on  the  head,  excessive  fatigue  or  excitement,  heat,  perhaps  some- 
times dentition,  and  also  various  inflammatory  and  febrile  affec- 
tions, especially  in  their  first  stages. 

Cerebral  symptoms  occurring  in  the  course  of  an  essential  fever 
are  no  doubt  often  due,  in  a  great  measure,  to  the  irritating  eft'ect 
on  the  brain  of  the  specific  principle,  whatever  it  may  be,  circu- 
lating in  the  blood.  Occurring  in  inflammatory  diseases  which 
are  located  elsewhere  than  within  the  cranium,  they  are  often 
attributed  to  functional  disturbance  of  the  brain.  The  brain,  it  is 
said,  sympathizes  with  the  aftected  part  through  the  system  of 
nerves  which  unite  them.  But  observations  show  that  symptoms 
referable  to  the  brain,  arising  in  the  commencement  of  the  essen- 
tial fevers  and  of  the  phlegmasia,  are  in  many  instances  preceded 
by,  and  are  therefore,  doubtless,  in  greater  or  less  degree  dependent 
on,  hypersemia  of  this  organ. 


CAUSES.  315 

Diflk'ult  as  it  is  to  ascertain  the  state  of  the  brain  in  many 
diseases  in  which  it  is  involved,  we  may  determine  whether  or 
not  there  is  congestion  in  the  young  child  by  observing  the 
anterior  fontanelle.  If  it  be  elevated  and  tense  in  an  acute 
disease,  hypcrremia  is  indicated.  Now,  it  is  often  unusually 
prominent  in  fevers  and  inflammations,  especially  in  their  first 
stages,  when  cerebral  symptoms  are  present.  Its  elevation,  under 
such  circumstances,  is  obviously  coincident  with  cerebral  con- 
gestion. 

The  acute  inflammations  which  are  most  likely  to  be  attended 
by  cerebral  congestion  are  those  of  the  mucous  surfaces,  and 
pneumonia.  Severe  coryza,  tracheo-bronchitis,  entero-colitis,  and 
colitis,  commencing  suddenly  with  great  febrile  excitement,  are 
frequently  accompanied  in  their  initial  stage  by  active  congestion 
of  the  cerebral  vessels.  Cases  like  the  following,  which  I  find  in 
my  note-book,  are  not  infrequent.  An  infant  four  months  old 
had  been  sick  about  two  days  with  coryza  and  bronchitis,  when 
I  was  called  to  see  it ;  the  pulse  numbered  156 ;  respiration  64 ; 
nursed,  and  was  somewhat  restless;  cough  frequent  and  dry; 
bowels  moderately  relaxed.  The  mucous  membrane  of  the  fauces 
was  injected,  and  coarse  mucous  rales  were  present  in  the  chest. 
The  anterior  fontanelle  rose  above  the  level  of  the  cranium,  and 
pulsated  forcibly.  Soon  after,  convulsions  occurred,  which  were 
relieved  by  appropriate  measures,  and  on  the  following  day  the 
fontanelle  had  subsided.  The  patient  gradually  recovered  without 
any  other  untoward  symptom. 

Cerebral  congestion  and  convulsions  often  mark  the  initial  stage 
of  active  intestinal  phlegmasise.  This  is  especially  true  of  dysen- 
tery. The  little  patient,  perhaps  from  the  very  inception  of  the 
colitis,  is  drowsy ;  its  surface  hot ;  j^ulse  full  and  rapid.  There  is 
sudden  and  momentary  starting  or  twitching  of  the  limbs.  The 
anterior  fontanelle,  if  still  open,  is  elevated,  and  it  is  not  till  the 
lapse  of  several  hours  that  the  cause  of  these  symptoms  is  apparent 
from  the  bloody  stools. 

The  causes  of  passive  congestion  of  the  brain  are  very  different 
from  those  of  the  active  form.  A  common  cause  is  obstructions 
in  a  sinus  or  vein  by  a  fibrinous  concretion,  or  by  a  tumor  or 
abscess  external  to  it. 

I  have  occasionally  met  cases  in  which  this  form  of  cerebral 
congestion  appeared  to  be  plainly  referable  to  obstruction  to  the 
return  of  blood  from  the  brain  by  the  pressure  of  bronchial  glands, 
enlarged  by  hyperplasia  in  tubercular  disease,  these  bodies  dimin- 


316  CONGESTION    OF    BRAIN. 

ishing  by  external  pressure  the  calibre  of  the  vense  innominat£e  or 
the  descendino;  vena  cava.  Rilliet  and  Barthez  have  called  atten- 
tion  to  such  cases  in  the  clinical  history  of  tuberculosis.  The  fol- 
lowing case  may  be  cited  as  an  example ;  it  occurred  in  the  infant's 
service  of  Charity  Hospital,  in  this  city,  in  April,  1866. 

An  infant,  about  one  year  old,  affected  with  tuberculosis,  both 
bronchial  and  pulmonary,  was  observed,  during  the  ten  days  pre- 
ceding its  death,  to  bore  the  pillow  with  its  head  almost  constantly, 
so  as  to  wear  the  hair  from  the  occiput.  This  movement  of  the 
head  was  the  only  prominent  cerebral  symptom.  ]N"othing  abnor- 
mal was  noticed  in  the  appearance  of  the  eyes,  nor  was  the  stomach 
irritable.  A  spasmodic  cough  and  progressive  emaciation  attracted 
attention,  but  these  were  referable  to  the  tubercular  disease.  At 
the  autopsy,  we  found  the  cerebral  sinuses,  veins,  and  capillaries 
greatly  congested.  On  tracing  the  veins  which  return  blood  from 
the  brain,  an  inflamed  and  enlarged  bronchial  gland  was  discovered 
in  the  angle  formed  by  the  convergence  of  the  right  and  left  vense 
innominatfc.  This  gland,  which  contained  but  a  single  point  of 
tubercular  exudation,  had  attained  such  a  volume  by  proliferation 
of  its  cells,  that  it  pressed  upon  both  vessels,  so  that  it  had 
obviously  retarded  the  circulation  in  each,  and  given  rise  to  the 
cerebral  congestion. 

Passive  congestion  often  occurs  in  the  infant  at  birth,  either 
from  tediousness  of  the  labor,  or  delay  in  the  expulsion  of  the 
body  after  the  birth  of  the  head.  If  it  is  simple  congestion, 
and  not  congestion  with  hemorrhage,  it  soon  passes  oft'.  Passive 
congestion  of  the  brain  also  occurs  in  severe  paroxysms  of 
hooping-cough,  in  which  return  of  blood  from  this  organ  is 
temporarily  retarded.  All  are  familiar  with  the  congestion  which 
occurs  in  parts  external  to  the  cranium,  from  the  severity  of  the 
cough;  producing  epistaxis,  extravasations  under  the  conjunctiva, 
etc.  The  extra-cranial  obviously  indicates  the  presence  and  degree 
of  cerebral  congestion. 

Those  who  practise  in  malarious  regions  sometimes  meet  cases 
of  dangerous  passive  congestion  of  the  brain,  the  result  of  malaria, 
occurring  especially  in  the  cold  stage  of  intermittent  fever.  In 
these  cases,  the  surface  is  pallid,  its  temperature  reduced,  and  the 
pulse  feeble.  The  blood,  leaving  the  peripheral  vessels,  collects 
in  undue  quantity  in  the  internal  organs,  producing  congestion  of 
the  brain,  as  well  as  of  the  thoracic  and  abdominal  viscera.  In 
the  child  with  malarious  disease,  in  whom  there  is  less  vigor  of 
constitution  than  in  the  adult,  death  not  infrequently  occurs  in 


^  ANATOMICAL    CUARACTEES.  317 

this  passive  congestion.  Two  such  cases  liave  occurred  in  my 
practice,  although  in  this  hititude  the  malarious  affections  are 
mild  in  comparison  with  the  type  which  they  present  in  many 
parts  of  the  United  States. 

Symptoms. — The  symptoms  of  active  congestion  of  the  brain 
are  stupor,  great  heat  of  head,  throbbing  of  carotids,  restlessness 
when  aroused,  twitching  of  the  limbs,  and  perhaps  convulsions. 
There  is  also  sometimes  intolerance  of  light,  and  the  anterior  fonta- 
nelle,  if  open,  pulsates  strongly.  In  passive  congestion  many  of 
the  symptoms  are  the  same  as  in  the  active  form.  Stupor,  twitch- 
ing of  the  limbs,  and  fretfulness  or  irritability  when  the  patient  is 
disturbed,  are  common,  ordinarily  without  increase  of  temperature ; 
the  surface  may,  indeed,  be  cool,  and  the  face  is  not  flushed  nor 
the  eyes  injected.  The  strong  pulsation  and  elevation  of  the  ante- 
rior fontanelle,  so  conspicuous  in  active  congestion,  are — the  former 
always,  the  latter  often — lacking.  In  both  forms  there  is  a  tendency 
to  constipation. 

In  many  cases  the  symptoms  of  congestion  of  the  brain  are 
associated  with  others  which  proceed  directly  from  the  cause  of 
the  congestion,  but  it  is  not  diflicult,  unless  in  exceptional  instances, 
to  determine  which  are  due  to  the  congestion,  and  which  to  the 
antecedent  and  coexisting  pathological  state. 

Anatomical  Characters. — In  active  congestion  there  is  an  ex- 
cess of  arterial  blood  in  the  brain  and  its  membranes.  The  arte- 
ries, to  their  minutest  branches,  are  seen  to  be  full,  presenting 
the  bright  hue  of  oxygenated  blood.  In  passive  congestion  the 
sinuses  and  veins  are  distended.  The  pia  mater,  choroid  plexus,  and 
the  vessels  of  the  brain,  have  a  darker  appearance  than  in  active 
congestion.  In  both  forms  of  congestion,  if  they  continue  for  a 
little  time,  other  anatomical  changes  occur.  If  there  is  great  dis- 
tension of  the  capillaries,  these  vessels  are  apt  to  give  way,  and  we 
find  here  and  there  little  patches  of  extravasated  blood.  In  other 
cases  the  over-distension  is  relieved  by  the  transudation  of  the 
serous  portion  of  the  blood  through  the  coats  of  the  vessels.  The 
cephalo-rachidian  fluid  is  then  found  in  excess  external  to  the 
brain  and  in  the  ventricles. 

Prognosis. — The  duration  and  the  result  of  congestion  of  the 
brain  depend,  in  great  measure,  on  the  nature  of  the  cause.  If 
the  cause  is  trivial,  as  mental  excitement,  fatigue,  exposure  to 
heat,  there  is  usually  prompt  relief  if  the  condition  of  the  patient 
is  understood  and  projjerly  treated.  If  the  cause  is  general  or  con- 
stitutional, as  one  of  the  essential  fevers  or  hooping-cough,  or  if  it 


318  CONGESTION    OF    BRAIN. 

is  local,  but  its  seat  external  to  the  cranium,  the  prognosis,  so  far 
as  the  congestion  is  concerned,  is  not  unfavorable,  if  there  is  a  timely 
and  judicious  use  of  remedies.  The  most  unfavorable  cases  are 
those  in  which  the  cause  is  seated  in  the  encephalon,  and  those  in 
which  there  is  some  obstructive  disease  in  the  course  of  the  circu- 
lation. Congestion  occurring  from  a  structural  change  within  the 
cranium  is,  from  the  nature  of  the  cause,  without  remedy,  and 
ordinarily  fatal.  Obstructive  diseases  of  the  circulatory  system, 
wherever  located,  being  for  the  most  part  permanent,  give  rise,  as 
a  rule,  to  incurable  congestion. 

Congestion  of  the  brain,  if  it  is  not  relieved  in  a  few  hours,  be- 
comes less  and  less  amenable  to  treatment.  It  soon  passes  beyond 
the  resources  of  our  art,  and  ends  in  coma ;  it  is  seldom  protracted 
beyond  a  few  days.  Extravasations  of  blood  common  in  active 
congestion,  and  serous  effusion  common  in  the  passive  form,  dimin- 
ish the  chances  of  a  favorable  result. 

Treatment. — The  indication  for  treatment  in  active  congestion 
is  plain.  Measures  should  be  emplo^^ed  which  have  a  derivative 
effect  from  the  brain.  Unless  there  is  an  asthenic  primary  aifec- 
tion,  in  the  course  of  which  the  congestion  is  developed,  active 
purgation  is  required.  A  saline  purgative  is  ordinarily  preferable. 
If  the  stomach  is  irritable,  there  is  no  better  purgative  than  calo- 
mel. In  all  cases  of  active  congestion,  whatever  the  cause,  the 
bowels  should  be  kept  open.  It  is  often  better  not  to  wait  for  the 
tardy  action  of  a  cathartic,  but  to  give  at  once  an  enema  of  soap 
and  water  or  salt  and  water.  External  derivative  agents  are  also 
indicated.  A  warm  mustai'd  foot-bath,  sinapisms  to  the  back  of 
the  neck  or  chest,  and  to  the  feet,  and  cold  applications  to  the 
head,  are  measures  which  should  never  be  neglected. 

This  treatment,  if  employed  early,  will  relieve  the  congestion  in 
a  large  proportion  of  cases ;  but  if  there  is  no  improvement,  if  the 
child  is  robust,  and  if  the  primary  affection  be  such  as  does  not 
contraindicate  loss  of  blood,  leeches  should  be  applied  to  the  tem- 
ples or  some  part  of  the  head.  If  after  the  lapse  of  some  hours 
cerebral  symptoms  continue,  apoplexy  or  serous  effusion  has  pro- 
bably occurred.  Congestion  is  then  no  longer  the  prominent  lesion, 
and  it  is  proper  to  designate  the  disease  by  another  name. 

The  treatment  appi-opriate  to  passive  congestion  is  somewhat 
different;  cold  applications  to  the  head,  and  those  of  a  derivative 
nature  to  the  extremities,  are  useful.  As  this  form  of  the  disease 
is  not  primarj-,  but  is  dependent  on  some  antecedent  pathological 
state,  it  is  evident  that  it  can  only  be  treated  successfully  by  re- 


I 


HEMORRHAGE  —  CAUSES.  319 

moving  or  obviating  as  f\ir  as  possible  the  cause.  But  the  nature 
of  the  various  obstructions  to  the  intra-craiiial  circulation  is  such 
that  our  ability  to  accomplish  this  end  is  very  limited. 

If  the  cause  is  constitutional,  or  if  it  be  some  disease  in  the 
neck  or  chest,  it  may  sometimes  be  partially  or  even  wholly  re- 
moved, but  if  seated  within  the  cranium  it  is  beyond  our  control. 
In  general,  it  may  be  said  that  depletion  is  not  required  or  tole- 
rated in  passive  congestion,  and  occasionally  stimulants  are  needed. 


CHATTER   VI. 

INTRA-CRAKIAL  HEMORRHAGE  (MENINGEAL  HEMORRHAGE- 
CEREBRAL  HEMORRHAGE). 

Hemorrhage  within  the  cranium  is  not  very  infrequent  in  in- 
fancy and  childhood;  and  there  is  no  part  of  the  encephalon, 
whether  the  meninges  or  brain,  in  which  it  does  not  sometimes 
occur.  If  the  blood  is  extravasated  upon  the  surface  of  the  brain 
or  between  the  meninges,  the  disease  is  designated  by  waiters 
meningeal  apoplexy;  if  in  the  substance  of  the  brain,  cerebral 
apoplexy.  Extravasation  may  also  occur  in  one  of  the  lateral 
ventricles.  This  may,  for  convenience,  be  described  as  a  form  of 
meningeal  aj^oplexy. 

Causes. — Apoplexy  is  usually  (there  is  an  exception)  preceded 
by  congestion.  If  the  congestion  increases  to  a  certain  degree,  the 
distended  capillaries  give  way,  and  extravasation  of  blood  results. 
Thenifore  the  causes  of  congestion  which  have  been  enumerated 
in  the  preceding  article  are,  in  great  measure,  those  of  apoplexy. 
Recent  microscopic  examinations  have  demonstrated  that  the  cor- 
puscular elements  of  the  blood  may  escape  from  capillaries  without 
rupture.  While,  therefore,  it  is  probable  that  intra-cranial  hemor- 
rhage in  early  life  commonly  occurs  from  a  rupture,  its  occasional 
occurrence  through  the  walls  of  the  capillaries  must  be  admitted. 

Intra-cranial  hemorrhage  is  not  infrequent  in  the  new-born.  It 
results  in  them  from  tediousness  of  the  birth,  and  severity  of  the 
labor-pains.  At  first  there  is  extreme  congestion  of  the  meningeal 
and  cerebral  vessels  corresponding  with  that  of  the  scalp  and  face. 
This  congestion  continuing,  soon  ends  in  extravasation  of  blood. 
In  some  of  these  cases  forceps  have  been  used  to  effect  the  delivery, 
but  it  is  doubtful  whether  the  use  of  instruments  materially  in- 


320  INTEA-CRANIAL    HEMORRHAGE. 

creases  the  congestion  or  the  amount  of  extravasation.  Certainl}' 
in  a  large  proportion  of  intra-cranial  as  well  as  supra- cranial  hemor- 
rhage of  the  new-born,  instruments  have  not  been  used.  An  addi- 
tional cause  of  the  hemorrhage  is  in  some  instances  the  use  of 
ergot,  which,  bj  producing  strong  and  continuous  pains,  interrupts 
the  placental  circulation  and  increases  the  congestion  of  the  foetal 
veins  and  capillaries. 

In  infants  a  few  days  old,  intra-cranial  hemorrhage  may  result 
from  that  rapid  and  fatal  disease,  tetanus  neonatorum.  The  liemor- 
rhage  is  preceded  by  intense  passive  congestion,  which  the  tetanic 
rigidity  and  spasms  produce  by  obstructing  respiration  and  circula- 
tion. Few  cases  of  tetanus  neonatorum  occur  without  more  or 
less  extravasation  of  blood,  either  meningeal  or  cerebral.  Another 
cause  of  this  disease  is  obstruction  in  the  vessels  which  return  the 
blood  from  the  brain.  The  various  structural  changes  which  pro- 
duce this  obstruction,  in  different  cases,  have  been  sufficiently 
described  in  our  remarks  on  cerebral  congestion  and  thrombosis. 

The  congestion  which  precedes  hemorrhage,  when  occurring  un- 
der the  conditions  described  above,  is  passive. 

Among  the  causes  which  produce  hemorrhage  through  the  inter- 
mediate state  of  active  congestion,  may  be  mentioned  great  mental 
excitement,  of  which  M.  Legendre  relates  a  case,  leugthened  expo- 
sure to  the  sun's  rays,  an  example  of  which  Rilliet  and  Barthez 
have  seen.  It  is  also  said  that  compression  of  the  aorta  by  an 
enlarged  liver  or  an  abdominal  tumor  has  sometimes  produced 
meningeal  or  cerebral  hemorrhage  by  causing  an  increased  afflux 
of  blood  to  the  head.  A  very  important  cause  to  which  I  have 
not  alluded,  is  that  general  state  of  the  circulatory  system  which 
is  designated  by  the  term  purpura  hemorrhagica.  This  sometimes 
results  from  the  anti-hygienic  conditions  in  which  the  child  is 
placed.  In  other  instances  it  results  from  some  antecedent  disease, 
protracted,  debilitating,  and  which  has  produced  a  profound  alter- 
ation in  the  state  of  the  blood  and  the  vessels.  The  capillaries 
l)ecome  less  firm  and  elastic,  and  easily  give  way,  so  that  in  such 
patients  ecchymotic  points  are  ordinarily  found  in  different  parts 
of  the  system.  The  diseases  which  occasionally  end  in  this  hemor- 
rhagic diathesis  are  numerous.  I  have  known  it  to  occur  after 
measles,  scarlet  fever,  and  smallpox.  It  is  also  an  occasional  sequel 
of  chronic  diarrhoea,  of  intermittent  and  typhoid  fevers,  and  of 
rachitis. 

Anatomical  Characters. — Hemorrhage  in  or  upon  the  brain  in 
infancy  and  childhood,  differs  in  important  particulars  from  that 


y 


ANATOMICAL    CHARACTERS.  321 

occurring  in  adult  life.  In  the  adult,  and  more  so  as  life  advances, 
the  arteries  become  less  distensible  and  more  brittle,  so  that  when 
hemorrhage  occurs  it  is  usually  from  one  of  these  vessels.  In  early 
life,  on  the  other  hand,  the  blood  does  not  ordinarily  escape  from 
an  artery,  but,  as  has  been  stated,  from  the  capillaries.  The  extra- 
vasation is  riot,  therefore,  so  rapid  and  violent,  and  is  not  attended 
with  such  laceration  and  injury  of  surrounding  parts,  in  infancy 
and  childhood,  as  at  a  subsequent  age.  In  the  adult,  the  hemor- 
rhage commonly  occurs  in  the  substance  of  the  brain.  The  flow 
of  blood  from  the  ruptured  artery  separates  the  brain-substance, 
producing  a  cavity  in  which  a  clot  forms.  This  constitutes  the 
usual  form  of  apoplexy  in  the  adult.  In  the  first  years  of  life,  on 
the  contrary,  the  extravasation  is  commonly  from  the  meninges, 
and  the  symptoms  to  which  the  effused  fluid  gives  rise  are  mainly 
referable  to  its  mechanical  eft'ect.  Cases  of  hemorrhage  in  the  sub- 
stance of  the  brain  constitute  a  small  minority,  unless  during  the 
days  immediately  succeeding  birth.  In  early  life,  therefore,  on  ac- 
count of  its  greater  frequency,  meningeal  hemorrhage  is  a  disease 
of  more  importance  than  cerebral,  and  its  anatomical  character 
should  be  carefully  studied. 

In  meningeal  hemoiThage  the  extravasation  may  be  between  the 
cranium  and  dura  mater,  upon  the  visceral  layer  of  the  arachnoid, 
in  the  meshes  of  the  pia  mater,  or  in  a  lateral  ventricle,  from 
rupture  of  the  capillaries  in  the  choroid  plexus.  Much  the  most 
common  seat  is  external  to  the  pia  mater  in  the  so-called  cavity 
of  the  arachnoid ;  the  blood  escaping  in  this  situation  spreads 
uniformly  in  all  directions.  It  soon  separates  in  two  portions,  the 
solid  and  liquid.  The  solid  portion,  or  the  clot,  is  free  or  but 
slightly  attached  to  the  adjacent  membrane.  The  meninges  in 
the  vicinity  of  the  extravasated  blood  preserve  their  normal 
appearance,  or  are  but  slightly  injected ;  the  clot  gradually  be- 
comes extended  on  all  sides,  so  as  to  form  a  lamina  at  the  seat  of 
the  extravasation,  thinner  at  its  circumference  than  centre,  and 
at  first  of  a  dark  red  color.  The  color  gradually  fades,  and  the 
lamina  becoming  smooth  and  polished,  and  at  the  same  time  more 
and  more  attenuated,  finally  resembles  the  arachnoid  in  appearance. 
Its  diameter  varies  in  different  cases  from  a  few  lines  to  two  or 
three  or  more  inches.  M.  Tonnele  relates  two  observations  in 
which  the  adventitious  membrane  extended  over  the  superior 
surface  of  both  hemispheres,  and  in  one  of  them,  also,  over  the 
falx  cerebri. 

The  extravasation  may  occur  at  any  part  of  the  surface  of  the 
21 


322  INTRA-CRANIAL    HEMORRHAGE. 

brain,  but  its  usual  seat  is  the  vertex.  The  next  most  frequent 
locality  is  the  base  of  the  brain.  The  subsequent  history  of  the 
delicate  membrane  into  which  the  clot  is  gradually  transfoi'med 
is  interesting.  It  often  extends  so  as  to  cover  more  space  than 
was  occupied  by  the  extravasated  blood,  and  its  edges  are  then 
scarcely  distinguishable,  in  consequence  of  their  extreme  tenuity, 
and  their  close  resemblance  to  the  arachnoid.  The  attachments  ot 
this  membrane,  so  far  as  it  forms  any,  are  usually  to  the  parietal 
surface  of  the  arachnoid.  Sometimes  a  portion  of  the  membrane 
is  attached,  while  the  rest  lies  free,  bathed  on  either  side  by  the 
liquid  portion  of  the  blood  which  still  remains  from  the  extravasa- 
tion. According  to  M,  Legend  re,  in  the  most  favorable  cases,  the 
serum  is  absorbed,  and  the  membrane  which  has  resulted  from  the 
clot,  and  which  I  have  described,  becomes  intimately  adherent  to 
the  internal  surface  of  the  dura  mater.  It  forms  an  integral  part 
of  this  membrane,  and  there  only  remain  a  little  thickening  and 
increased  ojiacity,  indicating  the  seat  of  the  extravasation.  The 
health  is  fully  re-established. 

But  the  result  in  other  cases  is  as  follows.  The  serum  is  not 
absorbed,  and  the  newly-formed  membrane,  uniting  at  points  with 
the  inner  surface  of  the  dura  mater,  or  its  arachnoidal  covering, 
incloses  the  fluid  so  as  to  produce  a  circumscribed  hydrocephalus. 

Sometimes  there  is  only  one  cyst ;  in  other  instances  the  mem- 
])rane,  especially  if  large,  unites  in  such  a  way  as  to  give  rise  to 
more  cysts  than  one.  The  size  of  the  cyst  varies,  according  to  the 
quantity  of  fluid,  which  may  be  only  a  few  drachms  or  several 
ounces.  Rilliet  and  Barthez  report  a  case  in  which  there  was  a 
pint  of  fluid  lying  over  each  hemisphere,  there  being  two  cysts. 
If  the  cranial  bones  are  not  united,  so  that  they  yield  to  the  pres- 
sure, the  size  of  the  cranium  is  increased,  and  if  the  extravasation 
is  confined  to  one  side,  an  inequality  results,  and  the  sjniimetry  of 
the  head  is  destroyed.  The  fluid  which  causes  the  enlargement  of 
the  head  in  such  cases,  is  in  part  the  serum  of  the  extravasated 
blood,  and  in  part  a  subsequent  secretion. 

Various  writers  relate  cases  of  ventricular  hemorrhage.  Valleix 
met  it  in  an  infant  that  died  at  the  age  of  two  days.  In  the  Edin. 
Journ.  of  Med.  cmd  Surg.,  October,  1831,  an  interesting  case  is 
related.  A  boy,  nine  years  old,  died  of  hemorrhage  in  both  ven- 
tricles, and  also  at  the  base  of  the  brain  and  in  the  spinal  canal. 
In  the  jS^ursery  and  Child's  Hospital  of  this  city,  the  post-mortem 
examination  was  made  of  an  infant  who  died  at  the  age  of  one 
mouth.     In  the  posterior  cornu  of  the  left  lateral  ventricle  were 


CEREBRAL    HEMORRHAGE.  323 

two  clots,  elongated  and  black,  one  larger  than  the  other.  In  the 
corresponding  cornu,  on  the  opposite  side,  was  a  smaller  clot.  A 
similar  post-mortem  ajipearance  was  observed  at  the  autopsy  of  a 
young  infant  in  the  infant  service  of  Charity  Hospital.  A  dark 
crescentic  clot  lay  in  each  posterior  cornu.  The  clot,  if  remaining 
a  long  time,  undergoes  degeneration.  In  one  case  of  an  adult,  in 
which  a  year  had  elapsed  after  the  extravasation,  I  found  it  to  con- 
tain crystals  of  cholesterine  and  carbonate  of  lime. 

Cerebral  hemorrhage,  or  hemorrhage  in  the  substance  of  the 
brain,  may  occur  at  any  time  in  infancy  and  childhood.  The  blood 
is  sometimes  extravasated  in  points,  here  and  there,  over  the  entire 
organ,  or  a  part  of  the  organ ;  in  other  cases  it  is  extravasated  in 
one  or  perhaps  two  cavities,  as  in  the  ordinary  form  of  apoplexy  in 
the  adult.  In  the  first  form  of  cerebral  hemorrhage,  or  that  in 
which  the  blood  escapes  from  numerous  points  through  the  brain, 
there  is  evidently  little  laceration  or  injury  of  the  organ.  The 
brain-substance  surrounding  the  hemorrhagic  points  sometimes 
preserves  the  usual  appearance.  It  is  white  and  firm.  In  other 
cases  it  presents  a  reddish  or  yellowish  appearance,  and  is  softened 
to  the  depth  of  a  line  or  two.  If  the  hemorrhage  occur  in  a 
cavity,  as  in  apoplexy  of  adults,  the  nerve-fibres  are  evidently  torn 
and  separated,  and  there  is  more  or  less  compression  of  the  sur- 
rounding brain-substance.  Unless  the  disease  is  of  long  standing, 
the  cavity  contains  a  dark  and  soft  clot  bathed  with  serum,  which 
has  a  reddish  or  a  yellowish-red  appearance.  The  brain  in  the 
immediate  vicinity  of  the  cavity  is  sometimes  softened.  Rilliet 
and  Barthez  state  that  they  have  seen  eight  cases  of  cerebral 
hemorrhage  of  the  capillary  form ;  ten  cases  in  which  the  hemor- 
rhage was  in  cavities ;  and  in  two  of  the  eighteen  both  forms  were 
present.  In  five  of  those  in  which  the  form  was  capillary  the 
disease  was  limited  to  portions  of  the  brain,  while  in  the  remaining 
three  the  hemorrhagic  points  were  found  in  nearly  every  part  of 
the  brain. 

Apoplectic  cavities  are  seldom  seen  in  the  cerebellum,  and, 
wdiether  the  hemorrhage  be  capillary  or  in  a  cavity,  there  is,  in 
most  cases,  as  previously  stated,  more  or  less  congestion  of  the 
vessels  of  the  brain. 

The  proportion  of  cases  of  cerebral  to  other  forms  of  hemorrhage 
is  believed  by  some  to  be  greater  in  the  new-born  than  at  any 
other  period  of  life.  Valleix  relates  four  cases  of  intra-cranial 
hemorrhage  occurring  at  this  age,  two  of  which  were  cerebral,  one 
ventricular,  and  in  the  other  the  extravasation  was  in  the  cavity  of 


324  CEREBRAL    HEMORRHAGE. 

the  araclinoicl.  Mignot  has  published  eight  cases  occurring  in  the 
new-born,  in  two  of  which  the  hemorrhage  was  in  cavities  in  the 
cerebrum ;  in  three,  in  the  lateral  ventricles ;  and  in  three,  external 
to  the  brain.  If  the  same  proportion  be  observed  in  other  statistics, 
one  in  three  of  the  cases  of  intra-cranial  hemorrhage  occurring  in 
the  new-born  is  cerebral. 

Symptoms. — The  symptoms  in  intra-cranial  hemorrhage  are  not 
uniform ;  they  vary  according  to  the  seat  as  well  as  the  quantity  of 
the  eflused  blood.  In  some  cases  the  extravasation  occurs  without 
such  symptoms  as  would  direct  attention  to  the  brain.  When  the 
hemorrhage  occurs  at  the  time  of  birth,  in  consequence  of  the 
strong  and  long-continued  labor-pains,  the  infant  is  often  born 
apparently  dead.  This  is  due  partly  to  the  hemorrhage,  partly  to 
the  great  congestion  of  the  brain  which  precedes  and  accompanies 
the  hemorrhage.  Resuscitation  is  gradual  and  difficult.  The  in- 
fant's features  are  livid  and  perhaps  swollen,  its  respiration  is  gasp- 
ing, and  both  pulse  and  respiration  are  slow.  Its  cry  is  feeble, 
with  but  slight  movement  of  the  facial  muscles,  and  the  lungs  are 
but  partially  inflated;  the  eyelids  are  closed,  and  the  limbs  almost 
motionless.  By  artificial  respiration  and  by  friction,  the  pulse  and 
breathing  may  be  rendered  more  frequent,  but  the  latter  remains 
irregular  and  gasj^ing.  Finally,  the  limbs  grow  cold,  the  surface, 
from  a  state  of  lividity,  becomes  pallid,  and  death  occurs  in  pro- 
found coma.  M.  Cruveilhier  made  many  observations  at  the 
"Maternity"  in  reference  to  the  death  of  new-born  infants,  and  he 
believes  that  one-third  of  those  who  die  in  birth,  at  the  full  period, 
die  of  apoplexy.  I  have  made  post-mortem  examinations  in  a  few 
cases,  when  death  had  occurred  from  this  cause,  and  in  all  the 
hemorrhao-e  was  menino;eal.  One  of  these  was  born  on  the  30th 
of  December,  1864.  The  birth  was  delayed  by  unusual  projection 
of  the  promontory  of  the  sacrum,  so  that  finally  the  application  of 
forceps  was  necessary.  The  infant  was  apparently  stillborn,  but 
by  persistent  efitbrts  on  the  part  of  the  physician  who  assisted,  it 
was  resuscitated  so  as  to  live  several  hours,  though  with  constant 
•embarrassment  of  respiration  and  with  lividity.  At  the  autopsy 
-a  large  extravasation  of  blood  was  found  in  the  cavity  of  the 
arachnoid,  over  a  considerable  part  of  the  convexity  of  the  brain, 
and  the  substance  of  the  brain  was  deeply  congested. 

Apoplexy  in  the  new-born  does  not  always  terminate  fatally,  or, 
when  fatal,  in  the  sudden  manner  which  I  have  described.  Valleix 
relates  the  case  of  an  infant  who  died  of  pneumonia  at  the  age  of 
three  and  a  half  months.     Its  birth  had  been  protracted  and  diffi- 


SYMPTOMS.  325 

cult,  but  was  completed  without  the  use  of  instruments.  It  had 
had  during  its  entire  life  paralysis  of  the  right  side.  At  the 
autopsy  a  clot  was  found  near  the  base  of  the  right  thalamus 
opticus,  evidently  existing  from  birth.  Around  the  clot  the  brain 
was  softened  to  the  depth  of  some  lines,  and  was  of  a  bluish-red 
color.  A  very  similar  case  is  related  by  M.  Vernois.  An  infant 
lived  forty-nine  days  with  paralysis  of  the  left  side,  and  died  of 
pneumonia.  At  the  autopsy  a  hemorrhagic  excavation  in  the  pro- 
cess of  cicatrization  was  found  behind  the  right  corpus  striatum 
and  the  thalamus  opticus. 

Intra-cranial  hemorrhage  occurring  from  accidents  of  birth  is 
generally  attended  by  marked  sjaiiptoms,  such  as  have  been  de- 
scribed. But  when  it  occurs  subsequently  to  birth,  whether  in 
infancy  or  childhood,  the  symptoms  vary  greatly  in  difi'erent  cases, 
and  are  generally  obscure.  I  will  briefly  state  the  symptoms  which 
have  been  observed  in  both  the  cerebral  and  meningeal  forms  of 
this  disease.  First,  the  cerebral.  Sedillot  relates  the  case  of  a 
child  seven  and  a  half  years  old,  whose  bare  head  had  been  exposed 
several  hours  to  the  sun's  rays.  Suddenly,  after  a  paroxysm  of 
anger,  it  was  seized  with  great  pain,  corresponding  with  the  pos- 
terior and  inferior  fossae  of  the  cranium.  It  uttered  piercing  cries, 
and  died  in  a  quarter  of  an  hour.  A  clot  was  found  in  the  right 
lobe  of  the  cerebellum.  Richard  Quinn  (Rilliet  and  Barthez) 
gives  the  history  of  a  boy  nine  years  old,  who  in  j3laying  with  a 
hoop  suddenly  stopped,  carried  his  hands  to  his  head,  and  fell 
backwards  unconscious.  Three  or  four  hours  afterwards,  when 
examined,  he  was  found  pale,  surface  cool,  respiration  slow  and  at 
times  stertorous,  pulse  50  to  60  per  minute;  the  left  arm  was 
flexed ;  the  left  leg  paralyzed ;  the  right  leg  and  arm  convulsed ; 
right  pupil  strongl}^  dilated,  the  left  contracted.  He  died  seven 
hours  after  the  commencement  of  the  attack,  and  a  large  clot  was 
found  in  the  centrum  ovale  on  the  right  side. 

Rilliet  and  Barthez  relate  the  following  case  from  Campbell.  A 
boy  with  good  previous  health  was  suddenly  seized  about  7  A.M. 
with  repeated  vomiting,  and  in  an  hour  and  a  half  with  violent 
convulsions;  he  rolled  his  eyes  and  uttered  inarticulate  cries;  pulse 
frequent  and  hard ;  pupils  contracted ;  trunk  and  lower  extremities 
cool.  In  the  afternoon  he  presented  symptoms  of  compression  of 
the  brain,  such  as  dilatation  of  the  pupils,  frequent  and  feeble 
pulse.  Death  occurred  in  the  evening,  and  a  hemorrhagic  cavity 
was  found  occupying  the  right  middle  lobe  of  the  cerebrum. 
Guibert  relates  a  case  of  extravasation  in  the  superior  part  of  the 


326  CEEEBRAL    HEMORRHAGE. 

right  hemispliere  of  the  brain  in  a  boy  fourteen  years  old.  The 
principal  symptoms  were  feebleness  of  the  limbs,  inability  to  walk, 
cephalalgia,  involuntary  evacuations,  fever,  grinding  the  teeth, 
rigors  severe  and  prolonged,  lividity,  loss  of  intellectual  faculties, 
dilatation  of  the  pupils,  insensibility  to  light,  stertorous  respiration. 
Death  occurred  in  about  an  hour. 

Rilliet  and  Barthez  narrate  the  history  of  a  girl  two  years  old, 
who,  after  an  attack  of  measles,  was  taken  with  convulsions  accom- 
panied with  fever  and  prostration.  The  convulsive  movements 
affected  especially  the  eyes  and  upper  extremities ;  the  right  leg 
was  immovable ;  the  left  pupil  dilated.  These  symptoms  resulted 
from  hemorrhage  in  the  corpus  striatum  and  opticus  thalamus. 
The  same  authors  relate  also  the  case  of  a  girl,  seven  years  old,  who 
died  with  a  large  apoplectic  cavity  in  the  left  thalamus  opticus. 
The  symptoms  were  headache,  convulsive  movements,  loss  of  con- 
sciousness, delirium,  vomiting  and  constipation,  convergent  stra- 
bismus. These  symptoms  nearly  disappeared,  but  in  a  few  days 
the  headache  returned,  with  strabismus  and  a  slight  drawing  of 
the  face  towards  the  left;  on  the  twenty-seventh  day  there  were 
some  convulsive  movements  of  the  right  eye,  with  paralysis  of  the 
arm.  Finally  contraction  of  the  arms  occurred,  with  acceleration 
of  pulse,  irregular  breathing,  dilated  pupils,  paralysis,  and  retraction 
of  the  head,  followed  by  death  on  the  forty-eighth  day. 

These  cases,  and  those  from  Yalleix  and  Vernois,  which  have 
been  related  in  our  remarks  on  hemorrhage  of  the  new-born,  are 
sufficient  to  show  the  character  of  the  symptoms  in  that  form  of 
cerebral  hemorrhage  in  which  the  extravasated  blood  forms  a 
cavity  in  the  interior  of  the  brain. 

If  the  amount  of  extravasation  is  large,  and  the  substance  of  the 
brain  is  much  lacerated  and  compressed,  death  may  occur  almost 
immediately,  and,  therefore,  without  symptoms,  or  before  it  is 
possible  to  determine  whether  or  not  symptoms  are  present.  If 
the  disease  is  not  so  speedily  fatal,  the  symptoms,  as  appears  from 
the  above  cases,  are  headache,  confusion  of  thought,  or  even  insen- 
sibility, cries,  sometimes  piercing,  cold  extremities,  pallor,  slow 
and  perhaps  stertorous  respiration,  convulsive  movements  followed 
by  paralysis,  or  convulsions  affecting  one  or  more  limbs,  with 
paralysis  of  others,  pupils  contracted  or  dilated,  sometimes  one 
contracted  and  the  other  dilated,  strabismus,  rolling  of  eyes, 
vomiting. 

These  symptoms  have  all  been  observed  in  different  cases,  but 
they  are  not  all  present  in  any  one  case.     Those  which  are  gene- 


SYMPTOMS.  327 

rally  present,  and  on  which  we  mainly  rely  for  diagnosis,  arc 
headache,  convulsive  movements,  paralysis,  confusion  of  thought, 
irregularity  in  the  pupils,  and  strabismus. 

In  the  CAPILLARY  form  of  cerebral  hemorrhage  there  is  usually 
some  complication,  so  that  it  is  not  easy  to  determine  how  far 
symptoms  are  due  to  the  hemorrhage,  and  how  far  to  the  coexist- 
ing pathological  state. 

There  are,  indeed,  but  few  published  observations  of  capillary 
hemorrhage  in  the  substance  of  the  brain  uncomplicated  with 
meningeal  hemorrhage,  hemorrhage  in  a  cavity,  or  some  other  and 
distinct  disease,  but  so  far  as  I  have  been  able  to  ascertain  the 
symptoms  referable  to  this  form  of  extravasation,  they  are  as  fol- 
lows :  The  child  is  drowsy ;  fretful  when  disturbed ;  it  perhaps 
moans.  There  are  sometimes  slight  convulsive  movements  and 
partial  paralysis.  If  there  is  considerable  extravasation,  the  re- 
spiration is  irregular  and  sighing.  Death  occurs  in  coma,  occa- 
sionally preceded  by  convulsions.  Taupin  relates  the  case  of  a 
child  nine  years  old,  who  died  with  this  form  of  hemorrhage, 
accompanied  by  softening  of  the  brain.  The  disease  began  at 
night,  with  delirium,  agitation,  and  piercing  cries.  In  the  morn- 
ing, the  patient  lay  in  bed,  drowsy,  not  complaining  of  pain,  and 
not  replying  to  questions;  pupils  dilated,  and  insensible  to  light; 
left  eye  half  open  during  sleep,  and  its  axis  changed ;  eyebrows 
contracted ;  face  pale ;  mouth  open  ;  had  no  convulsions,  but  tran- 
sient stiffening  of  the  limbs,  during  which  the  thumbs  were  firmly 
compressed  by  the  fingers  ;  senses  unimpaired,  but  the  face  drawn 
to  the  right ;  deglutition  difficult ;  pulse  small,  irregular,  and 
feeble ;  respiration  32,  sighing.  In  the  evening  he  had  rigidity 
of  the  limbs  and  back,  and,  finally,  was  taken  with  general  con- 
vulsions, in  which  he  died  at  eleven  o'clock.  The  hemorrhagic 
points  in  this  case  were  numerous.  A  boy  five  years  old,  whose 
case  is  described  by  Rilliet  and  Barthez,  died  of  this  disease,  pneu- 
monia, and  white  softening  of  the  intestine.  During  the  last  five 
days  there  were  cerebral  symptoms,  the  chief  of  which  were 
drowsiness,  fretfulness  when  disturbed,  and  moaning  without  ap- 
parent cause.  Another  child,  whose  case  is  described  by  Rilliet 
a,nd  Barthez,  died  at  the  age  of  four  years,  with  cerebral  capillary 
hemorrhage,  accompanied  by  yellow  softening.  Six  months  before 
death  he  had  general  convulsions,  followed  by  spasmodic  move- 
ments of  the  left  side.  These  subsided,  but  the  left  side  remained 
feeble. 


328  CEEEBRAL    HEMORRHAGE. 

In  MENINGEAL  HEMORRHAGE  there  are  ofteii  convulsions,  general 
or  partial,  in  some  patients  tonic,  in  others  clonic.  When  partial, 
the  convulsive  movements  may  only  occur  in  the  muscles  of  the 
face  and  eyes.  With  the  spasmodic  muscular  action  is  a  degree  of 
drowsiness  and  irritability.  Paralysis,  so  common  in  the  apoplexy 
of  the  adult,  and  not  infrequent,  as  we  have  seen,  in  the  cerebral 
form  of  early  life,  is  sometimes,  but  not  ordinarily,  present  in 
meningeal  hemorrhage.  Instead  of  paralysis,  there  are  vomiting, 
some  febrile  action,  thirst,  and  loss  of  appetite.  The  symptoms 
are  difterent,  however,  according  to  the  exact  seat  of  the  hemor- 
rhagic extravasations,  and  the  duration  of  the  disease.  If  the 
extravasation  end  in  the  formation  of  a  cyst,  the  symptoms  are 
those  of  hydrocephalus.  The  following  condensed  history  of  cases 
which  I  have  selected  as  typical,  will  give  us  a  clearer  idea  of  the 
history  and  course  of  the  various  forms  of  meningeal  hemorrhage 
than  can  be  imparted  by  a  narration  of  symptoms: — 

M.  Tonnel^  relates  the  case  of  a  child  who  was  taken  with  faint- 
ness  and  convulsive  movements.  On  the  following  day  the  trunk 
and  inferior  extremities  became  rigid ;  deglutition  was  painful ; 
the  pupils  were  largely  dilated,  immovable;  face  pale;  pulse  feeble 
and  intermittent.  Death  occurred  the  same  day.  The  dura  mater 
was  distended.  A  layer  of  coagulated  blood,  of  great  thickness, 
extended  over  the  convexity  of  each  hemisphere.  The  veins 
ramifying  in  the  superior  part  of  each  hemisphere  were  distended 
with  coagulated  blood.  The  hemorrhage  was  in  the  meshes  of  the 
pia  mater.  Drs.  Lombard  and  Panchard,  of  Geneva,  relate  a  some- 
what similar  case.  A  child  thirteen  months  old  was  convalescing 
from  inflammation  of  the  bronchial  and  intestinal  mucous  surfaces, 
when  it  was  seized  with  general  convulsions ;  the  mouth  and  eyes 
were  open,  and  the  eyes  directed  upwards ;  pupils  contracted ; 
pulse  frequent  and  irregular.  The  convulsions  abated  somewhat, 
but  soon  reappeared  with  violence.  The  patient  became  insensible, 
and  died  nineteen  hours  after  the  commencement  of  cerebral  symp- 
toms. The  extravasated  blood  covered  the  upper  surface  of  both 
hemispheres.  From  the  above  cases  we  see  the  symptoms  and  the 
couree  of  meningeal  hemorrhage,  when  the  extravasation  is  so 
large  that  death  speedily  results.  In  protracted  cases  of  meningeal 
hemorrhage,  there  is  either  a  gradual  disappearance  of  symptoms 
and  return  to  health,  or,  circumscribed  hydrocephalus  occurring,  the 
symptoms  of  that  disease  arise. 

Diagnosis. — It  is  evident  from  what  has  been  stated  that  the 
diagnosis  of  intra-cranial  hemorrhage  is  attended  with  unusual 


PROGNOSIS — TREATMENT.  829 

difficulty,  since  the  symptoms  of  tlii^^  disease  occur  also  in  otlier 
and  distinct  pathological  states.  The  history  of  the  case,  and 
especially  the  character  of  the  cause,  if  ascertained,  will  aid  in 
diagnosis.  If  there  has  been  an  obvious  determination  of  blood 
to  the  brain,  or  some  known  obstruction  to  the  return  of  blood 
from  that  organ,  the  persistence  of  cerebral  symptoms  would 
justify  us  in  concluding  that  either  serous  or  sanguineous  eft'usion 
had  supervened  on  a  state  of  congestion.  The  points  of  ditierential 
diagnosis  between  apoplexy  and  meningitis  are  the  sudden  and 
full  development  of  symptoms  in  one  case,  the  gradual  commence- 
ment and  gradual  increase  of  symptoms  in  the  other ;  differences 
also  of  symptoms  in  certain  respects ;  for  example,  as  regards  febrile 
reaction,  constipation,  etc. 

There  is  one  symptom  in  cerebral  hemorrhage  which  is  of  great 
diagnostic  value,  namely,  paralysis.  Its  progress  affords  strong 
evidence  that  there  is  extravasation  of  blood,  and  probably  in  a 
cavity  in  the  substance  of  the  brain.  If  the  extravasation  end  in 
the  formation  of  a  cyst,  the  symptoms  and  appearances  of  hydro- 
cephalus, which,  after  a  time,  arise,  throw  light  on  the  nature  of 
the  disease. 

Prognosis. — There  can  be  no  doubt  that  many  cases  of  intra- 
cranial hemorrhage  occur  and  terminate  favorably  without  the 
nature  of  the  disease  being  suspected.  In  such  cases  the  amount  of 
extravasated  blood  is  small  or  moderate.  In  several  published 
cases  in  which  the  accuracy  of  the  diagnosis  was  shown  by  post- 
mortem examinations,  the  patients  were  convalescing  from  the 
hemorrhage  when  they  succumbed  to  intercurrent  diseases.  If, 
however,  the  amount  of  extravasated  blood  is  such  as  to  give  rise 
to  those  symptoms  which  have  been  described,  the  prognosis  is  un- 
ffivorable.  Recurring  convulsions,  and  persistent  stupor  from 
which  it  is  difficult  to  arouse  the  patient,  are  unfavorable  symp- 
toms. If  the  convulsions  cease,  and  consciousness  returns,  even  if 
there  is  paralysis,  the  result  may  be  favorable. 

Treatment. — The  proper  treatment  in  intra-cranial  hemorrhage 
depends  on  the  state  of  the  patient,  the  time  which  has  elapsed 
since  the  extravasation,  and  the  degree  of  it,  as  shown  by  the 
nature  and  severity  of  the  symptoms.  If,  as  is  often  the  case,  the 
jDatient  is  robust,  and  is  visited  soon  after  the  commencement  of 
the  attack,  cold  applications  should  be  made  to  the  head,  mustard 
to  the  back  of  the  neck  and  perhaps  chest,  and  derivation  should 
be  produced  by  mustard  pediluvia.  In  many  cases,  especially  in 
active  congestion,  it  is  advisable  to  apply  leeches  to  the  temples, 


830  CONGENITAL    HYDROCEPHALUS. 

and  the  bowels  should  be  opened  by  a  stimulating  enema.  In 
active  congestion,  also,  prompt  purgation  by  salines  or  other  ca- 
thartics is  sometimes  of  great  importance.  The  object  of  such 
treatment  is  to  relieve  congestion  of  the  cerebral  and  menins-eal 
vessels,  and  thereby  prevent  further  extravasation  of  blood.  If 
the  congestion  be  active,  the  pulse  continue  full  and  frequent,  and 
the  face  be  flushed,  it  is  proper  in  many  cases  to  control  the  action 
of  the  heart  by  a  sedative.  For  this  purpose  the  tincture  of  vera- 
trum  viride  may  be  given  in  doses  of  one  drop  to  a  child  five  years 
old,  repeated  in  three  hours  if  necessary,  or  aconite  may  be  employed. 
If  the  stupor  or  convulsions  continue  after  sufiicient  time  has 
elapsed  for  the  patient  to  receive  the  full  benefit  of  the  above 
remedies,  more  active  counter-irritation  is  required.  Cantharidal 
collodion  should  be  applied  behind  each  ear.  If  the  hemorrhage 
occur  from  passive  congestion,  or  in  a  cachectic  state  of  system, 
active  depressing  remedies  should  not  be  employed.  External 
derivatives  are  of  service,  as  well  as  cool  applications  to  the  head, 
and  we  should  attempt,  so  far  as  possible,  to  remove  the  cause  of 
the  congestion  and  hemorrhage.  If  it  depend  on  a  cachectic  state, 
tonic  or  other  remedies  calculated  to  relieve  this  state  are  indicated. 
The  hemorrhage  from  such  a  cause  is  apt  to  be  in  points  in  the 
substance  of  the  brain,  or  in  moderate  quantity  over  the  surface  of 
this  organ,  and  by  a  timely  use  of  constitutional  remedies  possibly 
we  may  prevent  further  extravasation  of  blood  and  increase  the 
chance  of  the  patient's  recovery. 

If  a  cyst  result  from  the  hemorrhagic  effusion,  the  treatment 
which  is  proper  is  that  described  in  the  chapter  on  Acquired 
Hydrocephalus. 


CHAPTER  VII. 

CONGENITAL  HYDROCEPHALUS. 

Congenital  hydrocephalus  consists  in  an  excess  of  the  cerebro- 
spinal fluid,  lying  either  external  to  the  brain,  or  more  frequently 
in  its  interior.  It  is  due  to  some  vice  in  the  development  of  the 
brain  or  its  membranes,  or  to  a  pathological  state  occurring  in  them 
during  intra-uterine  life.  This  disease  is  ordinarily  apparent  from 
the  symptoms  and  appearances  at  birth,  but  not  always.  Occasion- 
ally nothing  unusual  is  observed  in  the  shape  of  the  head  or  aspect 


ANATOMICAL    CHARACTERS. 


331 


of  tlie  infant  till  after  the  lapse  of  some  weeks,  when  tlic  charac- 
teristic pliysiognomy  begins  to  appear.  In  these  cases  the  disease 
is  still  congenital,  as  there  is  every  reason  to  believe  that  the  ab- 
normal state  to  which  the  excessive  production  of  fluid  is  due 
existed  from  birth.  In  cases  of  arrested  or  partial  development  of 
the  brain,  as,  for  example,  when  a  considerable  portion  of  the 
hemispheres  is  absent,  there  is  often  an  unusually  large  quantity 
of  fluid  which  serves  merely  as  a  compensation  for  the  lack  of 
brain.  I  do  not  regard  such  cases  as  examples  of  hydrocephalic 
disease,  since  the  eflect  of  the  fluid  is  not  injurious,  but  rather 
useful.  I  restrict  the  term  congenital  hydrocephalus  to  those 
cases  in  which  the  brain  is  complete,  or,  if  incomplete,  the  quantity 
of  fluid  is  more  than  suflacient  to  supply  the  deficiency. 

Anatomical  Characters. — According  to  M.  Breschet,  the  fluid 
in  congenital  hydrocephalus  may  be — 1st,  between  the  dura  mater 
and  the  cranium ;  2d,  between  the  dura  mater  and  the  parietal 
arachnoid;  3d,  in  the  cavity  of  the  arachnoid;  4th,  in  the  ventri- 
cles; 5th,  between  the  arachnoid  and  the  brain. 

In  a  large  majority  of  hydrocephalic  patients  the  seat  of  the 
eflTusion  is  the  ventricles.  As  the  quantity  of  fluid  increases,  the 
pressure  from  within  gradually 
unfolds  the  convolutions  of  the 
brain,  at  the  same  time  produc- 
ing expansion  of  the  cranial  arch. 
When  the  amount  of  fluid  is  con- 
siderable, and  it  becomes  so  in 
the  course  of  a  few  weeks  or 
months,  the  hemispheres  are 
spread  out  in  a  thin  lamina  on 
either  side,  gradually  decreasing 
in  thickness  from  the  base  of  the 
cranium  to  the  vertex,  where  the 
brain-substance  is  sometimes  so 
thin  as  to  be  scarcely  perceptible. 
Complete  absence  of  brain  in  this 
situation,  namely,  at  the  vertex, 
even  in  extreme  cases  of  expansion  and  flattening  of  the  hemi- 
spheres from  the  pressure  of  the  liquid  is  rare,  though  the  brain- 
substance  at  this  point  is  sometimes  almost  as  thin  as  either  of 
the  membranes,  so  that  the  wall  of  the  sac  is  translucent.  The 
membranes  which  surround  the  brain  do  not  usually  undergo  any 
alteration,  except  such  as  arises  from  the  distension.     The  falx 


Congenital  hydrocephalus.    (From  Gross.) 


832  CONGENITAL  HYDROCEPHALUS. 

cerebri  sometimes  disappears,  and  sometimes  the  meninges  present 
a  whiter  hue  from  maceration  than  in  health.  The  distension  also 
causes  such  an  expansion  of  the  pia  mater  that  it  becomes  very 
thin,  and  in  places  scarcely  visible,  but  its  presence  in  every  point 
can  be  demonstrated. 

The  changes  which  the  cranial  bones  undergo,  both  in  their 
chemical  character  and  in  their  shape,  in  hydrocephalic  patients, 
if  the  amount  of  fluid  is  considerable,  are  interesting  and  remark- 
able. The  base  of  the  cranium  undergoes  little  change,  but  those 
portions  of  the  frontal,  parietal,  and  occipital  bones  which  con- 
stitute the  arch  are  expanded  in  all  directions,  while  they  become 
much  thinner.  There  is  deficiency  of  lime  in  their  constitution, 
so  that  their  organic  elements  are  greatly  in  excess.  This  renders 
them  flexible  and  semi-transparent.  Notwithstanding  the  expan- 
sion of  the  bones,  there  are  usually  interspaces  between  them,  of 
greater  or  less  size,  according  to  the  amount  of  fluid. 

The  scalp,  being  stretched  by  the  pressure  within,  becomes  tense 
and  thin,  and  is  scantily  covered  with  hair.  The  veins  which 
ramify  in  it  are  unusually  prominent  and  large,  and  the  head  is 
elastic  on  pressure,  from  the  amount  of  liquid  beneath.  In  the 
common  form  of  congenital  hydrocephalus,  namely,  that  in  which 
the  liquid  is  in  the  interior  of  the  brain,  the  shape  of  the  orbital 
plates  of  the  frontal  bone  is  changed,  so  that  the  eyeballs  have  a 
downward  direction.  This  change  in  the  axis  of  the  eyes  occurs 
at  an  early  period,  and  it  continues  through  the  entire  disease, 
becoming  more  and  more  marked  as  the  quantity  of  liquid 
increases.  If  the  amount  be  large,  the  lower  part  of  the  cornea  is 
buried  under  the  under  eyelid,  while  the  conjunctiva  is  visible 
between  the  cornea  and  the  upper  eyelid.  The  persistent  down- 
ward direction  of  the  eyes  is  characteristic  of  this  disease,  and,  in 
connection  with  enlargement  of  the  head,  is  an  important  diag- 
nostic sign. 

If  we  examine  the  interior  of  the  cavity  after  the  fluid  is  evacu- 
ated, we  will  find  at  its  base  the  parts  which  lie  in  the  floor  of  the 
lateral  ventricles,  but  changed  in  appearance  in  consequence  of 
pressure.  The  cornua  are  enlarged,  and  the  thalami  optici  and 
corpora  striata  are  flattened.  In  the  early  stages  of  the  disease, 
when  the  amount  of  fluid  is  small,  there  is  probably  no  absorption 
or  destruction  of  parts  in  the  interior  of  the  brain.  The  various 
portions  of  this  organ  retain  nearly  their  normal  relation  to  each 
other.     As  the  quantity  of  fluid  increases,  the  foramen  of  Monro, 


ANATOMICAL    CHARACTERS.  333 

which  unites  the  lateral  ventricles,  becomes  enlarged,  the  septum 
lucidum  which  separates  them  disappears,  and  the  two  ventricles 
form  a  common  cavity.  In  most  fatal  cases  we  find  this  single 
large  cavity.  The  surface  which  surrounds  the  cavity  occasionally 
presents  a  whitish  or  semi-opaque  appearance,  which  has  led  to  the 
belief,  on  the  part  of  some,  that  at  a  period  antecedent  to  birth 
there  was  subacute  inllanimation  of  this  surface,  and  hence  the 
eftusion. 

The  bones  of  the  face  are  ordinarily  less  developed  than  in 
healthy  children  of  the  same  age,  so  that  the  disproportion  between 
the  head  and  face  becomes  a  marked  peculiarity.  The  shape  of  the 
forehead  and  face  is  nearly  triangular. 

The  foregoing  remarks  in  reference  to  the  anatomical  characters 
of  congenital  hydrocephalus  refer  in  the  main  to  cases  which  have 
continued  for  a  considerable  time,  so  that  their  characteristic 
features  are  well  marked.  In  very  young  infants,  in  whom  the 
disease  is  still  recent,  similar  anatomical  characters  are  present,  but 
in  less  degree. 

Congenital  hydrocephalus  is  often  associated  with  other  vices  of 
conformation,  especially  with  spina  bifida.  The  two,  when  coex- 
isting, are  only  parts  of  the  same  disease ;  the  large  quantity  of 
cerebro-spinal  fluid  preventing  the  spinal  canal  from  closing  during 
foetal  development. 

The  fluid  in  congenital  hydrocephalus  consists  largely  of  water, 
in  the  proportion  even  of  99  parts  in  100.  In  addition  to  this 
element,  there  are  traces  of  albumen,  chloride  of  sodium,  phos- 
phate and  carbonate  of  soda,  and  osmazome. 

I  have  had  an  opportunity  to  witness  only  one  post-mortem 
examination  in  a  case  of  congenital  hydrocephalus  in  which  the 
liquid  was  exterior  to  the  brain.  This  case  was  under  observation 
in  the  children's  service  of  Charity  Hospital,  in  1866.  Full  notes 
and  measurements  of  the  head  were  taken,  which  unfortunately 
were  mislaid  or  lost.  The  infant  had  congenital  syphilis,  and  had 
a  pallid,  strumous  appearance.  The  shape  and  relative  size  of  the 
head  are  seen  in  the  accompanying  figure,  from  a  photograph. 
While  the  whole  head  was  enlarged,  there  was  a  relative  excess 
of  development  in  the  part  between  and  above  the  ears.  The 
axis  of  the  eyes  was  not  at  all  changed,  and  the  vision  was  good. 
The  appearance  corresponded  so  closely  with  descriptions  of 
hypertrophy  of  the  brain,  that  this  was  supposed  to  be  the  ana- 
tomical state.     Antisyphilitic  treatment  was  employed,  and  the 


331 


CONGENITAL    HYDEOCEPH ALUS, 


syphilitic  eruptions  had  nearly  disappeared, 
when  diarrhoea  supervened,  followed  by 
death.  At  the  autopsy,  a  quantity  of 
transparent  or  light  straw-colored  liquid, 
estimated  at  six  or  seven  ounces,  was  found 
exterior  to  the  brain,  in  the  great  cavity  of 
the  arachnoid,  lying  mostly  over  the  supe- 
rior surface  of  the  organ.  There  was  no 
excess  of  liquid  in  the  ventricles,  and  the 
brain,  though  of  good  size,  was  not  abnor- 
mally large,  nor  did  it  possess  the  firmness 
which  is  present  in  true  hypertrophy. 
All  cases  of  congenital  hydrocephalus  may  be  embraced  in  two 
groups,  namely,  that  in  which  the  liquid  is  in  the  interior  of  the 
brain,  and  that  in  which  it  lies  exterior  to  the  organ.  Liquid 
primarily  in  the  arachnoidean  cavity  permeates  the  meshes  of  the 
pia  mater,  and  lies  in  part  underneath  it,  or  this  delicate  membrane 
may  be  ruptured.  Four  of  the  groups,  therefore,  described  by 
Breschet,  may  properly  be  reduced  to  one,  namely,  those  groups  in 
which  the  liquid  lies  under,  between,  or  external  to  the  meninges. 
It  is  probable  that  some  of  the  cases  which  led  to  Breschet's  classi- 
fication were  examples  of  acquired  circumscribed  hydrocephalus, 
the  result  of  extravasation  of  blood.  In  this  form  of  hydrocephalus, 
as  is  stated  elsewhere,  an  adventitious  membrane  forms  external 
to  the  liquid,  becoming  in  time  thin  and  delicate,  and  often  bearing 
a  close  resemblance  to  the  normal  membrane  (especially  the 
arachnoid),  for  which  it  is  sometimes  mistaken. 

Symptoms. — If  there  is  a  considerable  amount  of  hydrocephalic 
fluid  prior  to  the  birth  of  the  child,  so  that  the  head  is  abnormally 
large,  parturition  is  seriously  interfered  with.  The  scalp  and 
meninges  may  become  ruptured  by  the  severity  of  the  pains  so 
that  the  fluid  escapes.  If  this  does  not  occur,  the  labor  is  often 
necessarily  instrumental.  Whether  the  liquid  is  present  before 
birth  or  accumulates  subsequently  to  it,  the  tendency  is  to  an 
increase  of  the  quantity,  and  a  corresponding  enlargement  of  the 
head. 

The  digestive  function  in  this  disease  is  at  first  well  performed. 
The  infant  nurses  readily,  and  has  its  evacuations  with  the  regu- 
larity of  other  children.  Not  many  weeks,  however,  elapse,  in  the 
majority  of  cases,  before  defective  nutrition  is  apparent. 

While  the  volume  of  the  head  increases,  other  parts  are  im- 
perfectly nourished  and  stunted  in  their  growth.     Emaciation  is 


SYMPTOMS.  335 


common  of  the  neck,  trunk,  and  limbs,  associated  with  progressive 
feebleness.  In  the  last  stages  of  this  disease  there  is  more  or  less 
vomiting,  with  constipation.  If  there  was  previously  the  ability 
to  support  the  head,  it  is  now  lost,  and  the  erect  position  is  no 
longer  possible.  In  marked  cases,  when  there  is  great  disproportion 
between  the  head  and  the  rest  of  the  system,  there  is  frequently 
not  even  the  ability  to  rotate  the  head  on  the  pillow.  As  long  as 
the  cranial  bones  yield  readily  to  the  pressure  from  within,  and 
there  is  no  compression  of  the  brain,  the  function  of  this  organ  is 
not  seriously  impaired.  The  child  recognizes  its  mother  or  nurse, 
and  it  can  be  amused  like  other  children,  though  easily  fatigued. 
The  state  of  the  senses  is  different  in  different  cases,  and  some- 
times at  different  stages  of  the  same  case.  The  sight  and  hearing 
in  some  are  perfect,  in  others  impaired ;  while  in  others  still  they 
are  good  at  lirst,  but  gradually  become  obscured  and  lost.  It  is 
said  that  the  sense  of  smell  may  be  perverted  so  that  agreeable 
odors  are  unpleasant,  and  vice  versa.  Many,  reaching  the  age  at 
which  children  begin  to  walk,  cannot  walk,  or  if  they  do,  it  is  with 
a  tottering,  unsteady  gait. 

When  the  liquid  increases  to  that  extent,  and  it  usually  does 
sooner  or  later,  that  the  brain  begins  to  be  compressed,  dangerous 
cerebral  symptoms  arise.  The  child  becomes  drowsy,  and  takes 
less  notice  of  objects.  There  are  twitching  of  the  limbs  and  finally 
convulsions.  The  pupils  act  feebly  or  irregularly  by  light,  or  one 
is  more  dilated  than  the  other.  Strabismus  also  occurs.  As  a  fatal 
termination  approaches,  convulsions  occur,  partial  or  general.  These 
are  soon  succeeded  by  the  last  stage,  that  of  coma,  in  which  the 
patient  expires. 

The  following  case,  which  I  copy  from  my  note-book,  is  an 
example  of  the  common  form  of  congenital  hydrocephalus.  It  will 
give  an  idea  of  the  ordinary  course  of  this  disease,  and  show  the 
difficulty  which  we  meet  with  in  its  treatment.  Female,  born 
ISTov.  9,  1859,  with  the  aid  of  forceps.  At  birth  the  fontanelles 
were  unusually  large,  the  cranial  bones  separated,  and  the  aspect 
in  a  marked  degree  hydrocephalic.  She  nursed  at  first,  but,  the 
mother's  milk  failing,  she  was  afterwards  bottle-fed.  At  the  age  of 
four  months  her  head,  which  had  increased  faster  than  her  general 
growth,  measured  from  one  auditory  meatus  to  the  other,  over  the 
vertex,  seventeen  inches ;  the  occipito-frontal  circumference,  twenty- 
three  inches.  At  this  time  she  manifested  considerable  intelli- 
gence, being  able  to  distinguish  her  mother  from  other  persons, 
tliough  the  head  was  so  large  that  it  was  necessary  to  support  it 


336  CONGENITAL    HYDROCEPHALUS. 

constantly  on  a  pillow.  From  the  age  of  four  to  six  months  the 
operation  of  tapping  was  performed  six  times  with  a  small  hydro- 
cele trocar,  by  Prof.  Stephen  Smith,  at  a  point  near  the  coronal 
suture  and  from  an  inch  to  an  inch  and  a  half  from  the  sagittal. 
At  each  operation  an  amount  of  fluid  varying  from  twelve  ounces 
to  one  pint  was  removed,  and  the  head  then  covered  with  strips  of 
adhesive  plaster,  so  as  to  form  a  complete  cap.  It  was  necessary, 
however,  within  the  twelve  hours  succeeding  each  operation,  to 
loosen  the  dressing,  on  account  of  either  the  occurrence  of  convul- 
sions or  symptoms  premonitory  of  them.  The  head,  within  a  week 
subsequently  to  each  operation,  regained  its  former  size,  and  as 
there  was  no  permanent  benefit,  this  treatment  was  discontinued. 
She  finally  died  of  entero-colitis  at  the  age  of  ten  months  and  five 
days. 

At  the  autopsy  the  distance  from  one  auditory  meatus  to  the 
other  was  twenty  and  a  quarter  inches;  the  occipito-frontal  cir- 
cumference, twenty-six  and  a  quarter  inches.  The  anterior  fonta- 
nelle  measured  antero-posteriorly  four  and  three-fourths  inches; 
transversely,  seven  and  three-fourths  inches.  The  parietal  bones 
were  separated  from  each  other  to  the  distance  of  two  or  three 
inches,  and  they  measured  in  length  nine  and  one-half  inches. 

On  opening  the  cranial  cavity,  seven  pints,  by  measurement,  of 
transparent  fluid  escaped,  exposing  a  vast  open  space,  at  the  bottom 
of  which  were  the  parts  which  constitute  the  floor  of  the  ventri- 
cles, somewhat  changed  in  shape,  and  from  them,  on  either  side,  the 
hemisphere  was  spread  in  a  lamina,  so  as  to  cover  the  internal  sur- 
face of  the  cranial  bones.  The  laminae  near  the  base  of  the  brain 
measured  in  thickness  from  half  an  inch  to  one  inch,  and  they 
gradually  became  thinner  on  approaching  the  vertex,  at  which 
point  the  brain-substance  was  exceedingly  thin,  so  as  to  be  scarcely 
demonstrable. 

The  brain  had  its  normal  vascularity  and  consistence,  and  the 
cerebellum,  medulla  oblongata,  the  base  of  the  brain,  and  cranial 
nerves  presented  their  usual  appearance.  On  folding  the  brain 
together,  it  had  the  size,  shape,  and  aspect  of  this  organ  in  its 
ordinary  development,  l^othing  unusual  was  observed  in  the  mem- 
branes except  their  gre'at  expansion.  The  above  case  corresponds 
in  its  general  features  with  most  cases  met  in  practice. 

Diagnosis, — The  ordinary  form  of  congenital  hydrocephalus, 
that  in  which  the  liquid  occupies  the  interior  of  the  brain,  can,  in 
most  cases,  be  readily  diagnosticated.  If  there  is  only  a  moderate 
amount  of  liquid,  it  may  be  confounded  with  hypertrophy  of  the 


PROGNOSIS  —  TREATMENT.  337 

brain.  In  hydroceplialns  there  is  commonly  more  rapid  growtli, 
and  greater  expansion  of  tlie  head;  moreover,  the  enlargement 
occurs  equally  on  all  sides,  while  in  hypertrophy,  though  all  parts 
of  the  cranial  vault  are  expanded,  the  enlargement  is  more  at  the 
vertex  than  elsewhere.  The  sign,  however,  of  greatest  diagnostic 
value  is  the  direction  of  the  axis  of  the  eyes.  In  hypertrophy  the 
axis  is  unchanged,  while  in  this  form  of  hydrocephalus,  although 
the  amount  of  liquid  may  be  small,  the  change  of  axis  occurs  which 
is  described  above.  In  rachitis  the  volume  of  the  head  is  often 
considerably  enlarged,  due  sometimes,  in  part  at  least,  to  a  deposit 
of  calcareous  matter  on  the  exterior  of  the  cranial  bones.  The 
differential  diagnosis  is  based  on  the  shape  of  the  head,  round  in 
one,  square  or  with  prominences  in  the  other,  on  palpation,  direc- 
tion of  the  eyes,  etc.  The  smaller  the  amount  of  liquid,  the  greater 
the  liability  to  error  of  diagnosis ;  but  if  the  amount  is  inconsider- 
able and  not  increasing,  little  treatment  is  required,  except  hygienic 
and  tonic,  which  is  also  proper  in  both  hypertrophy  and  rachitis. 
If  the  liquid  is  exterior  to  the  brain,  as  in  the  case  represented 
on  page  384,  diagnosis  may  be  difficult,  but  such  cases  are  infre- 
quent. 

Prognosis. — This  is  unfavorable.  The  amount  of  liquid  in 
congenital  hydrocephalus,  as  already  stated,  commonly  increases. 
The  most  favorable  result  is  no  increase,  or  but  slight,  in  the 
quantity,  while  the  natural  growth  of  the  infant  continues,  and 
thus  the  disproportion  between  the  head  and  the  rest  of  the  system 
gradually  disappears.  This  result  is  exceptional.  Ordinarily, 
while  the  quantity  of  fluid  increases,  the  nutrition  of  the  body 
and  limbs  is  more  and  more  deficient.  The  patient,  if  not  cut  oft" 
by  some  intercurrent  disease,  finally  succumbs  with  cerebral  sj^mp- 
toms  produced  by  pressure  of  the  fluid.  The  majority  of  those 
affected  with  congenital  hydrocephalus  die  in  infancy,  but  some 
enter  childhood,  and  occasionally  one  reaches  even  adult  life. 
Cases  of  recovery  have  been  reported,  but  if  they  were  genuine, 
the  disease  was  evidently  mild,  and  the  amount  of  liquid  small  or 
moderate. 

Treatment. — It  is  a  proper  question,  in  many  cases,  whether 
anything  should  be  done  to  relieve  the  hydrocephalic  infant  besides 
attending  to  its  general  health.  The  anxiety  of  parents,  however 
hopeless  the  nature  of  the  case  if  left  to  itself,  reported  recoveries, 
and  the  fact  that  we  have  medicines  which  in  many  instances 
diminish  the  amount  of  liquid  in  the  internal  cavities,  incline  us 
to  the  use  of  therapeutic  measures. 
22 


3o8  ACQUIRED    HYDROCEPHALUS. 

"We  may  attempt  to  diminish  the  quantity  of  fluid  by  the  use  of 
diuretics.     Digitalis,  squills,  nitrate  and  acetate  of  potash,  have 
been  used.     Probably  the  most  efficient  diuretic  in  these  cases  is 
iodide  of  potassium.     This  may  be  given  in  doses  of  one  to  two 
grains  every  two  hours  to  an  infant  of  six  months.     Constipation, 
if  present,  should  be  relieved  by  an  occasional  purgative.     If  it  is 
tolerated,  we  may  partially  prevent  the  expansion  of  the  head  by 
a  close-fitting  cap.     For  this  purpose  strips  of  adhesive  plaster, 
about  one-third  of  an  inch  in  width,  should  be  applied  so  as  to 
cover  the  entire  head.     The  proper  way  of  applying  these  is  as 
follows :  first,  one  strip  from  each  mastoid  process  to  the  outer  part 
of  the  orbit  on  the  opposite  side ;  secondly,  from  the  back  of  the 
neck,  along  the  longitudinal  sinus,  to  the  root  of  the  nose  ;  thirdly, 
over  the  whole  head,  so  that  the  difterent  strips  will  cross  each 
other  at  the  vertex ;  and,  lastly,  a  strip  long  enough  to  pass  three 
times  around  the  head  should  be  aj^plied,  passing  above  the  eye- 
brows, the  ears,  and  below  the  occipital  protuberance.     Too  tight 
an  application  should  be  avoided,  as  it  may  give  rise  to  convulsions 
or  other  cerebral  symptoms.     If  the  cap  can  be  tolerated,  and  the 
general  health  is  good,  the  prospect  is  more  favorable;  but  usually, 
from  the  increase  in  the  quantity  of  fluid,  it  is  necessary  in  a  few 
days  to  remove  or  loosen  the  plasters  in  order  to  prevent  convul- 
sions.    If  this  treatment  is  not  successful,  we  may  finally  resort 
to  tapping.     The  mode  of  performing  this  operation  has  already 
been  indicated  in  the  case  which  I  have  detailed,     ISTo  appreciable 
good  result  has  followed  the  use  of  irritating  or  sorbefacient  appli- 
cations in  this   disease.      ISTutritious   diet  and  attention  to   the 
general  health  are  requisite. 


CHAPTER  VIII. 
ACQUIRED  HYDROCEPHALUS. 

Hydrocephalus,  or  dropsy  of  the  brain,  may  also  occur  in  those 
who  at  birth  are  well  formed  and  free  from  disease.  Pathologists 
call  this  acquired  hydrocephalus.  It  is  in  nearly  all  cases  the 
result  of  disease,  which  is  located  sometimes  within  the  cranium, 
but  often  in  other  parts  of  the  system. 

Causes. — The  diseases  within  the  cranium  which  most  frequently 


ANATOMICAL    CHARACTERS.  389 

produce  serous  cft'usion  are  the  meningeal  inflammations,  l)otli 
simple  and  tubercular,  tumors  or  other  causes  which  obstruct  the 
venous  cii'culation,  and  hemorrhao'ic  effusion  endino;  in  the  forma- 
lion  of  cysts.  Prolonged  passive  congestion  often  ends  in  transu- 
dation of  serum  through  the  coats  of  the  capillaries.  Therefore, 
all  those  causes  of  congestion,  except  such  as  have  a  transient  or 
momentary  etfcct,  may  be  regarded  as  causes  of  serous  effusion. 

Among  the  diseases  external  to  the  cranium  which  produce 
serous  effusion  within  or  upon  the  brain,  may  be  mentioned  retro- 
pharyngeal abscess,  tubercularization  or  inflammation  of  the  bron- 
chial glands,  scarlet  fever,  and  certain  aflections  of  an  exhausting 
nature,  especially  protracted  diarrhceal  maladies.  In  four  cases 
w^hich  have  fallen  under  my  notice,  the  cause  was  enlarged  tuber- 
cular bronchial  glands,  which,  by  pressure  on  the  vense  innominatse, 
so  retarded  the  flow  of  blood  from  the  brain  as  to  cause  congestion 
and  efi'usion.  The  causative  relation  of  these  glands  to  cerebral 
congestion  is  more  fully  described  in  our  remarks  in  reference  to 
this  disease. 

Dropsy  of  the  brain  is  the  common  result  of  protracted  diar- 
rhceal affections  in  infancy,  whether  entero-colitis  or  non-inflamma- 
tory diarrhoea.  It  is  preceded  and  accompanied  by  passive  conges- 
tion of  the  cerebral  veins  and  sinuses,  due  in  part  to  feebleness  of 
circulation  in  consequence  of  the  exhausted  state  of  the  patient, 
and  in  part  to  the  wasting  of  the  brain,  which  always  gives  rise 
to  more  or  less  passive  congestion,  unless  in  young  infants,  in 
whom  the  cranial  bones  become  depressed  and  override  each  other. 
Dropsy  of  the  brain  resulting  from  scarlet  fever,  and  that  pecu- 
liar circumscribed  dropsy  which  results  from  hemorrhagic  effusions, 
are  described  elsewhere. 

A  few  cases  have  been  related  by  different  observers,  Aber- 
crombie  among  others,  in  which  dropsy  of  the  brain  seemed  to  be 
essential.  Nothing  abnormal  was  observed,  with  the  exception  of 
serous  effusion.  But  the  reports  of  such  cases  are,  for  the  most 
part,  meagre ;  and,  as  Barrier  has  well  said,  we  are  not  to  accept 
such  cases  as  examples  of  essential  dropsy  of  the  brain,  unless 
the  post-mortem  inspection  is  so  complete  as  to  render  it  certain 
that  there  was  no  antecedent  disease  to  which  the  dropsy  was  due. 

Anatomical  Characters. — Acquired  hydrocephalus  usually  oc- 
curs after  the  cranial  bones  are  firmly  united,  and,  therefore,  the 
shape  of  the  head  is  not  materiall}'  altered.  If  it  occur  at  an  early 
age,  before  there  is  firm  union,  there  may  be  expansion  of  the  cra- 
nial arch,  as  we  sometimes  observe  in  the  circumscribed  hydro- 


840  ACQUIRED    HYDROCEPHALUS. 

cephalus  resulting  from  liemorrliage.  The  effusion  in  acquired 
hydrocephalus  occurs  over  the  surface  of  the  hrain,  in  the  sub- 
arachnoid space,  or  in  the  lateral  ventricles.  In  the  dropsy  of 
protracted  diarrhoeal  maladies,  I  have  rarely  failed  to  find  the 
liquid  over  the  whole  superior  surface  of  the  brain  as  well  as  at  its 
base. 

The  quantity  of  fluid  in  this  disease  is  not  large.  In  the 
n)ajority  of  cases  it  does  not  exceed  four  ounces,  and  is  often  much 
less.  It  is  transparent,  or  it  has  a  slightly  yellowish  tinge.  The 
membranes  of  the  brain  sometimes  present  their  normal  appear- 
ance, but  in  other  cases  they  are  injected.  The  brain  itself,  in  some 
cases,  presents  an  injected  appearance  from  passive  congestion  of 
the  veins  and  sinuses ;  but,  in  other  cases,  when  there  has  been 
more  or  less  compression  of  the  brain,  there  is  no  more  than  the 
ordinary,  or  even  less  than  the.  ordinary  vascularity,  and  the  con- 
volutions are  somewhat  flattened. 

Symptoms. — -The  symptoms  of  the  pathological  state,  which 
gives  rise  to  the  dropsy,  precede  and  accompany  those  which  are 
referable  to  the  dropsy  itself.  The  dropsy  declares  itself  by 
symptoms  which  are  alarming  from  the  first. 

In  children  old  enough  to  speak,  or  manifest  intelligence,  there 
may  be  at  first  complaint  of  headache.  The  child  is  irritable,  its 
mind  confused  or  wandering  at  times,  or  there  is  actual  delirium. 
After  a  time  drowsiness  occurs.  The  head  seems  too  heavy  for 
the  body,  and  is  buried  in  the  pillow.  In  fatal  cases  the  features 
become  pallid,  the  pupils  sluggish,  and  perception  and  conscious- 
ness are  gradually  lost.  The  child  lies  in  profound  sleep,  which 
increases.  There  are  now  often  convulsive  movements,  partial  or 
general,  and  these  soon  end  in  coma,  in  which  the  patient  dies. 

Prognosis. — Acquired  hj'drocephalus  commonly  ends  unfavor- 
ably. The  prognosis  depends  not  only  on  the  quantity  of  liquid, 
but  on  the  nature  of  the  cause.  If  the  cause  be  venous  obstruc- 
tion within  the  cranium  or  thorax,  as  we  have  no  means  of  remov- 
ing it,  death  is  inevitable.  If  it  be  an  exhausting  disease,  as 
eutero-colitis  or  scarlet  fever,  although  the  case  is  not  absolutely 
hopeless,  the  prospect  is  still  unfavorable.  It  is  onlj'-  favorable 
when  the  quantity  of  eft'used  fluid  is  small,  the  system  not  much 
reduced,  and  the  primary  disease  mild.  AVhen  acquired  hydro- 
cephalas  arises  from  meningeal  apoplexy,  the  case  is  apt  to  be 
chroni<3.  The  symptoms  and  termination  of  this  form  of  the  dis- 
ease are  very  similar  to  those  in  congenital  hydrocejihalus. 


MENINGITIS,    SIMPLE    AND    TUBERCULAR.  341 

Treatment. — The  treatment  in  acquired  hydrocephalus  must 
vary  somewhat  in  ditierent  cases,  according  to  the  nature  of  the 
disease  on  which  it  depends.  I  shall  indicate  the  treatment,  in 
part  at  least,  in  the  description  of  these  diseases.  Occasionally  the 
condition  of  the  patient  is  such  that  there  is  little  to  encourage 
us  in  the  employment  of  any  remedial  measures.  In  vigorous 
children,  if  acquired  hydroce[)halus  occur  in  connection  with 
symptoms  which  indicate  too  active  a  circulation,  moderate 
abstraction  of  blood  from  the  temples  at  an  early  period  may  be 
useful,  but  cases  requiring  such  depletory  measures  are  rare. 
These  cases  require  cold  applications  to  the  head ;  the  bowels 
should  be  opened,  and  derivatives  should  be  applied  to  the  feet  and 
back  of  the  neck. 

If  the  congestion  be  of  a  passive  character,  as  when  the  circula- 
tion is  obstructed  by  tumors  or  otherwise,  benefit  may  still  be 
derived  from  cold  applications  to  the  head,  and  derivatives  to  other 
parts.  In  most  cases  of  suspected  dropsy  of  the  brain,  unless  the 
patient  is  in  such  a  hopeless  state  that  all  treatment  is  obviously 
futile,  vesication  should  be  produced  behind  the  ears.  I  prefer 
cantharidal  collodion  for  this  purpose.  In  addition  to  this  treat- 
ment, diuretics  should  be  employed,  unless  there  is  too  great  pros- 
tration, or  the  course  of  the  disease  is  so  rapid  that  no  benefit  can 
result  in  consequence  of  the  tardy  action  of  these  agents.  The 
best  diuretics  are  the  acetate  of  potash  and  iodide  of  potassium. 


CHAPTER   IX. 

MENINGITIS,  SIMPLE  AND  TUBERCULAR. 

The  most  interesting  and  important  disease  of  the  cerebro-spinal 
system  in  early  life,  is  that  which  is  now  designated  meningitis. 
It  is  not  infrequent.  The  mortuary  statistics  of  this  city  show 
that  it  is  the  cause  of  death  in  from  one  in  twenty-five  to  one  in 
fifty  of  the  entire  number  of  deaths,  the  proportion  varying  some- 
what in  difi:erent  years. 

In  1768,  the  attention  of  the  profession  was  particularly  called 
to  this  disease,  by  Dr.  "Whytt,  of  Edinburgh.  This  observer,  and 
the  pathologists  succeeding  him,  forming  their  opinion  of  menin- 
gitis from  its  most  prominent  anatomical  character,  namely,  serous 


842  MENINGITIS,    SIMPLE    AND    TUBERCULAR. 

eiFiision,  believed  it  a  dropsy.  They  accordingly  designated  it 
acute  hydrocephalus.  During  the  last  thirty  years  the  profession 
have  come  to  regard  the  disease  as  inflammatory,  and  hence  the 
name  by  which  it  is  now  known,  and  which  is  believed  to  express 
its  true  pathological  character. 

Sometimes  meningitis  in  children  is  an  idiopathic  disease.  In 
other  instances  it  occurs  to  those  afl:ected  by  tuberculosis,  and  in 
many,  if  not  in  all  such  patients,  there  are  tubercles  in  or  under  the 
meninges,  which  excite  the  inflammation  in  the  same  manner  as 
in  the  lungs  they  cause  pneumonitis  or  pleuritis.  Therefore  two 
forms  of  meningitis  are  recognized,  namely,  simple  and  tubercular, 

I  have  records  of  forty-five  fatal  cases  of  meningitis,  some  occvir- 
ring  in  my  private  practice,  and  the  remainder  in  institutions  of 
this  city  with  which  I  have  been  connected.  Post-mortem  exami- 
nations were  made  and  recorded  in  thirteen  of  them.  Twenty-five 
were  under  the  age  of  one  year,  of  which  fifteen  were  apparently 
well  when  the  meningitis  commenced,  belonging  for  the  most  part 
to  healthy  families;  three  were  feeble  and  cachectic,  but  apparently 
without  tubercles  ;  and  five  had  miliary  tubercles  in  various  organs, 
as  shown  by  post-mortem  examination.  The  condition  of  the 
other  two  was  not  recorded. 

Of  the  twenty  who  were  over  the  age  of  one  year,  the  majority^, 
namely,  thirteen,  presented  a  decidedly  cachectic  or  a  strumous 
aspect  before  the  meningitis  occurred,  and  a  considerable  number 
had  symptoms  of  pulmonary  tubercles.  These  statistics,  as  far  as 
they  go,  show  that  simple  meningitis  predominates  under  the  age 
of  one  year,  and  I  may  add  eighteen  months,  while  over  that  age 
the  tubercular  form  is  in  excess. 

The  belief  has  prevailed  in  the  profession,  that  tubercular  me- 
ningitis does  not  occur  in  j^oung  infants.  This  idea  is  fallacious, 
although,  as  has  been  stated,  meningitis  under  the  age  of  one  year 
is  more  frequently  independent  of  tubercles  or  the  tubercular  dia- 
theses than  associated  with  them.  Bouchut,  speaking  in  reference 
to  tubercular  meningitis,  says:  "Up  to  this  period  it  was  not 
believed  that  this  disease  existed  in  young  children,  for  no  mention 
is  made  of  it  in  the  works  of  Denis  and  Billard.  Still  its  existence 
at  this  age  is,  nevertheless,  incontestable.  MM.  de  Blache, 
G-uersant,  Rilliet  and  Barthez,  and  Barrier  have  observed  several 
examples  of  it,  and  I  have  collected  six  cases  of  this  disease  in  the 
practice  of  M.  Trousseau.  The  youngest  child  was  only  three 
months  old,  and  the  eldest  had  arrived  at  the  end  of  his  second 


MENINGITIS,    SIMPLE    AND    TUBERCULAR.  343 

year.  N'o  statiBtics  can  he  based  on  so  small  a  number  of  facts ; 
tlie  only  value  they  have  consists  in  their  overruling  an  opinion 
falsely  accredited  in  medical  science."  I  have  witnessed  the  post- 
mortem of  five  cases  of  tubercular  meningitis  occurring  in  chil- 
dren under  the  age  of  one  year,  as  is  seen  from  the  above  statistics, 
and  the  age  of  one  of  these  was  only  four  months.  In  two,  perhaps 
I  should  say  three,  of  the  five  the  presence  of  tubercles  in  the 
meninges  was  not  positively  demonstrated ;  but  in  all  of  the  five 
cases  miliary  tubercles  were  present  in  the  lungs  and  other  organs, 
so  that  I  did  not  hesitate  to  consider  the  meningeal  inflammation 
of  a  tubercular  character. 

In  patients  over  the  age  of  eighteen  months,  although  the  pro- 
portion of  tubercular  to  simple  cases  is  larger  than  under  this  age, 
the  excess  is  not  so  great,  according  to  my  statistics,  as  the  re- 
marks of  some  observers  would  lead  us  to  suppose.  There  can 
be  no  accurate  statistics  of  tubercular  meningitis  without  careful 
post-mortem  examination  of  the  state  of  the  brain  and  other  organs 
in  each  supposed  case,  and  this  examination  sometimes  shows  the 
meningitis  to  be  simple,  when  the  symptoms  and  physical  signs 
had  indicated  its  tubercular  character.  As  an  example,  may  be 
mentioned  a  case  which  occurred  in  the  children's  service  of  Charity 
Hospital,  in  March,  1868.  This  infant  died  at  the  age  of  twenty 
months,  having,  had  a  cough  of  moderate  severity  at  least  three 
weeks  before  death,  and  symptoms  of  meningitis  about  four  days. 
It  was  considerably  wasted,  and  was  supposed  to  have  tuberculosis. 
At  the  autopsy,  no  tubercles  were  found  in  any  part  of  the  body, 
but  parts  of  both  lungs  were  hepatized.  A  fibrinous  deposit,  varying 
in  thickness,  was  found  over  the  pons  Varolii,  the  optic  commis- 
sure, along  the  fissures  of  Sylvius,  over  the  superior  surface  of  the 
anterior  half  and  also  upon  the  posterior  lobe  of  each  cerebral 
hemisphere.  As  a  careful  examination  failed  to  discover  any  tuber- 
cles, the  meningitis  was  considered  simple.  Those  who  make 
these  examinations,  failing  to  find  tubercles  in  the  lungs  and  other 
organs  in  which  they  usually  occur,  should  examine  the  lymphatic 
glands,  for  cheesy  glands  may  be  the  cause  of  the  formation  of 
tubercles  in  the  meninges  while  the  organs  of  the  trunk  remain 
unaftected.  The  presence  of  cheesy  glands  in  the  absence  of  vis- 
ceral tubercles,  and  with  granulations  upon  the  meninges,  small, 
covered  with  fibrin,  and  of  a  doubtful  character,  goes  far  towards 
establishing  the  tubercular  nature  of  the  meningitis.  I  have  met 
with  one  such  case,  the  bronchial  glands  being  cheesy. 


3-i4-  MENINGITIS,    SIMPLE    AND    TUBERCULAR. 

Age. — The  following  table  gives  the  age  in  meningitis,  simple 
and  tubercular,  in  fortj-two  cases  in  my  collection: — 

Cases.  Age. 

1        .         .         .        .        2 i  weeks.     (Autopsy.) 


2 

20 

•  10 

5 

-4 

42 


3  mouths. 

From  3  to  12  months. 

"     1  year  to  2  years. 

' '    2  years  to  5     " 
Over  5  years. 


Eilliet  and  Barthez  have  also  published  statistics  of  the  age  in 
meningitis.  Their  cases  were  observed  chiefly  in  hospital  practice, 
and  the  result  is  somewhat  different. 

In  thirty-two  cases  of  simple  meningitis  observed  by  these 
authors,  eight  were  under  the  age  of  one  year,  six  from  two  years 
to  five,  and  eighteen  over  the  age  of  five  years.  In  ninety-eight 
cases  of  tubercular  meningitis,  there  w^ere  two  under  the  age  of 
one  year,  fifty-one  between  the  ages  of  one  year  and  five,  thirty- 
eight  between  the  ages  of  five  years  and  ten,  and  seven  between 
ten  and  fifteen  years. 

Anatomical  Characters. — The  dura  mater  in  meningeal  inflam- 
mation  is  either  not  affected,  or  is  affected  secondarily.  In  many 
cases  it  retains  its  normal  appearance,  its  internal  surface  remain- 
ing smooth  and  polished.  In  others  it  is  more  or  less  injected,  and 
the  surface  is  dim  or  lustreless.  Ordinarily,  also,  the  free  surface 
of  the  visceral  arachnoid  continues  unchanged,  but  sometimes  it 
becomes  dry  and  even  cloudy  or  oj)aque,  especially  where  it  covers 
those  parts  which  are  most  intensely  inflamed.  Exudation  rarely 
occurs  upon  this  surface,  however  intense  the  inflammation.  Those 
who  have  had  the  most  ample  opportunities  for  observation  record 
but  few  cases  of  it. 

In  both  forms  of  meningitis  the  inflammatory  action  commences 
in  the  pia  mater,  and  is  usually  confined  to  this  membrane.  In  its 
meshes,  or  underneath  them,  the  lesions  occur  which  characterize 
this  disease.  The  pia  mater  is  injected  over  a  greater  or  less  extent 
of  surface,  usually  in  tubercular  meningitis,  at  the  base  of  the  brain 
alone,  or  at  the  base  of  the  brain  and  in  less  degree  along  the  sides 
of  the  organ.  The  inflammation  is  ordinarily  most  intense  around 
the  pons  Varolii,  in  the  subarachnoid  space,  and  along  the  fissures 
of  Sylvius.  In  simple  meningitis  the  inflammation  may  also  be 
at  the  base,  but  in  other  cases  it  is  at  the  vertex.  It  is  at  the 
vertex  when  the  cause  is  exposure  to  the  sun's  rays.     In  addition 


ANATOMICAL  CHARACTERS.        "     345 

to  tlic  augmented  vascularity  of  the  pia  mater,  we  find  an  effusion 
of  serum,  fibrin,  and  pus,  tlic  quantity  and  proportion  of  these 
elements  varying  greatly  in  difierent  cases. 

The  exudation  of  fibrin  is  greatest  along  the  course  of  the  vessels, 
and  in  the  depressions  between  the  convolutions,  and  the  oi)acity 
is  most  marked  in  these  situations.  Pus,  when  present,,  is  almost 
semi-solid,  from  the  small  proportion  of  liquor  puris  which  it 
contains,  even  in  recent  cases.  If  the  disease  have  continued 
several  days,  the  liquor  puris  may  be  mostly  absorbed,  and  the  pus 
cells  becoming  shrivelled,  irregular,  and  aggregated,  may  resemble 
closely  the  cheesy  transformation  of  tubercle  cells. 

The  fibrinous  exudation  presents  features  of  interest.  It  does 
not  usually  attain  much  thickness,  but  by  its  opacity  it  conceals 
from  view  the  brain  underneath.  If  it  occur  in  the  fissures  of 
Sylvius,  the  anterior  and  middle  lobes  are  united  by  it.  It  is  usu- 
ally infiltrated  through  the  substance  of  the  pia  mater.  Some- 
times little  masses  of  variable  size,  often  not  as  large  as  a  pin's  head, 
appear  at  the  point  of  inflammation.  These  masses  are  firm,  of 
a  whitish  color,  or  a  light  yellow,  and  their  number  varies  in  dif- 
ferent cases.  They  consist  of  a  firm,  homogeneous  substance, 
containing  granular  matter,  and  cells  which  often  bear  a  close  re- 
semblance to  tubercle  corpuscles,  but  are  distinct.  These  corpuscu- 
lar bodies  are  plastic  nuclei  or  plastic  cells,  often  shrunken.  It  is 
seen,  then,  that  there  are  two  morbid  products  which  may  be  mis- 
taken for  tubercle:  one,  pus  which  has  been  in  great  measure 
deprived  of  its  liquid  element;  the  other, plastic  nuclei  collected  in 
little  bodies,  so  as  to  resemble  the  ordinary  form  of  crude  tubercle. 
I  once  carried  to  one  of  the  best  microscopists  and  pathologists  of 
this  city  some  of  the  exudation  from  a  case  of  meningitis,  the  cel- 
lular element  in  which  could  not  readily  be  distinguished  from 
shrunken  tubercle  corpuscles.  The  exudation  was  from  a  child 
two  years  and  eight  months  old,  with  good  health  previously  to 
the  meningitis ;  without  tubercles  in  any  part  of  the  body,  with 
parents  healthy,  and  with  no  predisposition  to  tubercular  disease. 
This  microscopist,  not  knowing  the  history  of  the  case,  or  character 
of  the  family,  and  ignorant,  like  all  of  us  at  that  time,  of  the  true 
tubercle  cell,  pronounced  the  exudation  tubercular  after  a  careful 
examination  with  the  microscope.  Bouchut  says :  "  The  whitish 
miliary  granulations  which  are  observed  on  the  surface  of  the  pia 
mater  have  a  certain  consistency  and  tenacity  which  render  them 
difficult  to  tear  with  the  needles  used  for  the  preparation  for  tlie 
microscope.     These  bodies  are  formed :  1.  Of  fibro-plastic  elements, 


346  MENINGITIS,    SIMPLE    AND    TUBERCULAR. 


whether  nuclei  or  fusiform  fibres ;  oval-shaped  cells  are  generally 
present,  but  not  always.  The  nuclei  are  oval  or  spherical,  gene- 
rally very  small — that  is  to  say,  they  hardly  exceed  in  diameter 
0.008  mm.  to  0.009  mm.  The  presence  of  these  little  spherical 
nuclei  must  be  insisted  on,  because,  with  a  less  power  than  5.50  dia- 
meters, it  would  be  sometimes  impossible  to  establish  the  differences 
which  separate  them  from  the  elements  of  tubercle ;  the  fusiform 
fibres  are  small  and  rare.  2.  There  exists  a  considerable  quantity 
of  amorphous  homogeneous  matter,  in  which  minute  granulations 
are  scattered:  it  is  very  dense,  and  keeps  the  other  elements 
strongly  united  together,  so  that  it  is  difiicult  to  isolate  them 
completely.  3.  Vessels  are  very  rarely  observed ;  the  fibres  of  cel- 
lular tissue  are  also  rare,  or  altogether  wanting." 

There  being  two  microscopic  elements  which  are  distinct  from 
tubercular  formations,  but  are  liable  to  be  mistaken  for  them, 
namely,  shrivelled  pus  cells  and  2:)lastic  nuclei,  more  or  less  altered, 
it  is  seen,  in  part  at  least,  why  the  older  writers,  and  some  of  a  more 
recent  date,  either  hold  that  all  meningitis  is  tubercular,  or  that 
there  are  comparatively  few  cases  of  the  simple  form. 

On  the  other  hand,  there  are  cases  of  true  tubercular  meningiti?; 
which,  even  with  a  pretty  careful  microscopic  examination,  might 
be,  and  probably  often  have  been,  regarded  as  simple.  In  order  to 
a  better  understanding  of  this  subject,  I  may  be  permitted  to  repeat 
certain  facts  already  stated  in  the  article  on  tuberculosis.  The 
views  of  pathologists  in  reference  to  what  is  the  primary  form  of 
tubercle,  and  what  is  and  what  is  not  tubercular  matter,  have 
recently  undergone  a  great  change.  It  is  now  believed  that  the 
tubercle  cell  is  a  round,  pale,  slightly  granular  cell,  identical  in 
appearance  with  the  normal  cell  of  the  lymphatic  glands,  being  in 
the  average  somewhat  smaller  than  the  white  corpuscle  of  the 
blood ;  that  it  is  produced  mainly  from  the  nuclei  of  the  connective 
tissue  by  proliferation ;  that  it  is  vitalized  like  other  cells,  and, 
of  course,  has  functional  activity;  that  the  true,  the  living  cell,  is 
found  onl}^  in  the  so-called  gray,  semi-transparent  tubercle.  It  is 
furthermore  believed,  that  what  has  heretofore  been  considered 
the  tubercle  cell,  namely,  the  irregular,  sometimes  angular,  some- 
times oval  cell — without,  indeed,  any  typical  form — may  be  a  dead, 
shrivelled,  and  altered  tubercle  cell,  or  a  dead,  shrivelled,  and 
altered  pus  or  other  cell.  If,  therefore,  such  cells  are  found  in  the 
meshes  of  the  pia  mater,  we  cannot  determine  from  the  microscope 
their  true  character.  We  can  only  form  our  opinion  in  reference 
to  their  nature  from  concomitant  circumstances,  or  from  discover- 


ANATOMICAL  CHARACTERS.  347 

ins:  in  connection  with  thorn  the  true  tubercle  cell.  TJiose 
products  which  have  been  designated  crude  tubercle  and  tuber- 
cular infiltration,  contain  these  shrivelled  cells,  or  shrivelled 
nuclei;  and  they  may  have  a  tubercular  origin,  or,  on  the  other 
hand,  an  inflammatory  origin,  without  either  the  tubercular 
product  or  diathesis. 

In  the  tuberculosis  of  young  children,  I  have  found,  in  a  large 
proportion  of  cases  in  which  I  have  had  an  opportunity  to  make 
post-mortem  examinations,  miliary  tubercles  disseminated  through 
the  lungs,  and  perhaj^s  other  organs,  in  small  masses,  many  of 
them  not  larger  than  a  pin's  head,  and  some  occurring  as  mere 
specks  scarcely  visible.  These  minute  tubercular  formations  have 
ordinarily  been  semi-transparent,  and  sometimes  even  transparent 
like  minute  drops  of  water,  and  containing  the  true  and  unchanged 
tubercle  cell.  'Now  if  in  such  a  case  meningitis  occur,  we  may 
find  the  tubercle  cell  in  or  with  the  fibrin  at  the  base  of  the  brain. 
But  failure  to  find  it,  even  with  protracted  microscopic  examina- 
tion, does  not  prove  its  absence  from  this  locality,  for  I  consider 
it  almost  impossible  to  discover  in  the  midst  of  the  fibrinous 
exudation  such  minute  points  of  tubercular  matter  as  are  seen  in 
the  lungs,  liver,  or  elsewhere.  In  view  of  these  facts,  I  know  no 
better  rule  for  the  practitioner,  who  cannot  command  the  time  for 
thorough  microscopic  examinations,  than  to  consider  as  tubercular 
all  cases  of  meningitis  in  which  tubercles  or  cheesy  glands  are 
observed,  in  whatever  part  of  the  system,  and  consider  as  examples 
of  simple  meningitis  all  those  cases  in  which  no  tubercles  are 
apparent  in  the  meninges  or  in  any  other  organ  of  the  trunk. 

The  pia  mater  is  often  firmly  adherent  to  the  brain  at  the  seat 
of  inflammation,  so  that  on  raising  it  a  portion  of  the  brain  may 
be  detached  and  removed  with  it.  The  extent  of  the  inflammation 
varies  much  in  ditFerent  cases.  There  may  in  extreme  cases  be 
pretty  general  inflammation  of  the  pia  mater.  In  cases  of  such 
extensive  meningitis,  the  symptoms  are  aj^t  to  be  severe,  and  the 
course  of  the  disease  rapid.  Thus,  in  the  month  of  April,  1866,  a 
girl  eleven  years  of  age,  in  the  Protestant  Episcopal  Orphan 
Asylum  of  this  city,  had  complained  occasionally  of  dizziness,  but 
was  otherwise  in  good  health,  cheerful,  and  with  excellent  appe- 
tite, till  Thursday,  when  she  was  affected  with  vertigo,  more 
persistent  than  previously,  and  with  headache.  At  2  P.  M.  on 
the  following  day  she  was  seized  with  general  convulsions,  and 
continued  insensible  or  nearly  so,  with  occasional  convulsive 
movements,  till  Monday,  when  she  died  comatose.     The  pia  mater 


348  MENINGITIS,    SIMPLE    AND    TUBERCULAR. 

at  the  vertex,  sides,  and  base  of  the  brain  had  a  cloudy  appearance, 
and  underneath  it,  in  places,  was  a  thick  creamy  substance  in 
small  quantity,  which,  examined  by  the  microscope,  proved  to  be 
pus,  the  largest  amount  being  near  the  pons  Varolii.  There  was 
no  tubercle  under  the  meninges  or  elsewhere,  and  no  appreciable 
fibrinous  exudation.  The  inflammation  in  this  case  was  obviously 
intense.  The  only  additional  lesions  noticed  were  moderate  con- 
gestion of  the  brain,  and  an  increase  in  the  quantity  of  the  cerebro- 
spinal fluid. 

If  the  disease  is  protracted  three  or  four  weeks,  which  is  rare,  or 
even  less  time,  the  exuded  substance  may  undergo  further  changes, 
such  as  occur  in  simple  exudations  in  other  parts  of  the  system. 
Thus,  on  the  30th  of  April,  1860,  we  made  the  post-mortem 
examination  of  an  infant  at  the  ISTursery  and  Child's  Hospital, 
who  had  symptoms  of  cerebral  disease,  it  was  stated,  for  several 
weeks,  but  the  exact  time  was  not  ascertained.  Prominent  among 
the  symptoms  referable  to  the  cerebro-spinal  system  towards  the 
close  of  life  were  the  hydrocephalic  cry  and  rigidity  of  the  neck. 
The  appearance  at  the  autopsy  was  remarkable.  The  anterior 
half  of  the  brain  was  completely  encased  in  a  deposit  which  had 
nearly  the  appearance  of  lard.  It  filled  the  fissures  of  Sylvius, 
and  appeared  slightly  on  the  anterior  aspect  of  the  cerebellum. 
Examined  under  the  microscope,  this  substance  was  found  to  con- 
tain numerous  cells,  among  which  could  be  distinguished  some 
resembling  pus  cells,  but  nearly  all  had  undergone  more  or  less 
fatty  degeneration.  Here  and  there  was  seen  a  large  cell  contain- 
ing numerous  small  oil  globules,  the  compound  granular  cell  of 
pathologists. 

The  brain  itself  in  meningitis  is  usually  injected.  On  making 
an  incision  through  it,  red  points  are  seen  upon  the  cut  surface, 
which  indicate  the  seat  of  the  congested  vessels.  The  inflamma- 
tion rarely  extends  to  the  walls  of  the  ventricles,  but  the  choroid 
plexus  is  injected.  In  exceptional  instances  ]3us  or  fibrin  is  found 
in  the  lateral  ventricles.  In  the  infant  two  and  a  half  weeks  old, 
whose  case  has  already  been  alluded  to,  about  two  ounces  of 
purulent  fluid  escaped  on  oiDcning  the  left  ventricle.  A  small 
amount  of  liquid  of  a  similar  character  was  contained  in  the  right 
ventricle.  The  distension  of  the  lateral  ventricles  with  serum  is 
one  of  the  common  results  of  menins-itis.  This  fluid  is  clear  or 
straw-colored,  or  it  is  turbid  in  consequence  of  being  mixed  more 
or  less  with  the  softened  brain-substance.  The  quantity  does 
not  exceed  two,  three,  or  four  ounces,  and  is  often  not  more  than 


CAUSES— PREMONITORY    STAGE.  349 

one  ounce  or  an  ounce  and  a  half.  The  distension  of  the  two 
ventricles  is  ordinarily  uniform,  as  they  are  united  by  tlie  foramen 
of  Monro,  but  now  and  then  one  ventricle  is  found  more  distended 
than  the  other.  If  there  is  considerable  effusion,  the  brain  is 
compressed  and  the  convolutions  have  a  flattened  appearance, 
unless  the  cranial  bones  are  still  separated  so  as  to  yield  to  the 
pressure.  If  the  sutures  and  fontanellcs  are  open,  the  cranial  arch 
is  expanded,  sometimes  quite  perceptibly  to  the  eye.  From  the 
same  cause  the  anterior  fontanelle,  if  open,  is  elevated.  The  foramen 
of  Monro  is  enlarged  according  to  the  amount  of  effusion,  and  the 
portions  of  the  brain  which  separate  the  ventricles  are  sometimes 
lacerated.  In  many  cases  the  cerebral  substance  surrounding  the 
lateral  ventricles  is  softened.  The  softening  is  found  in  all  degrees, 
from  the  least  appreciable  deviation  from  the  normal  consistence 
to  a  state  of  diffluence  so  that  the  brain  presents  the  appearance 
of  cream.  Hypotheses  have  been  advanced  to  explain  the  cause 
of  this  change  in  consistence,  which  are  not  entirely  satisfactory. 
Whatever  the  explanation,  the  fact  is  attested  by  all  observers, 
though  there  are  exceptional  cases.  Thus  Dr.  "West  has  records  of 
the  condition  of  the  brain  in  fifty-nine  cases,  in  thirty-seven  of 
which  there  was  considerable  softening,  and  in  the  remaining 
twenty-two  the  consistence  was  normal. 

Causes. — The  causes  of  simple  meningitis  are  not  fully  ascer- 
tained. Active  cerebral  congestion  frequently  occurring,  is  pro- 
bably a  common  direct  cause.  I  have  known  the  inflammation 
in  at  least  three  instances  to  occur  in  infants  from  four  to  eight 
months  old,  who,  a  month  or  six  weeks  previously,  had  severe 
and  protracted  attacks  of  bronchitis.  The  disappearance  of  erup- 
tions upon  the  scalp  prior  to  the  commencement  of  the  inflamma- 
tion, is  a  fact  often  observed.  I  have  noticed  this  before  the  com- 
mencement of  simple  meningitis,  as  well  as  before  meningitis,  if 
not  tubercular,  at  least  occurring  in  a  decidedly  scrofulous  state 
of  system.  I  have  already  alluded  to  a  case  in  which  the  inflam- 
mation, occurring  in  the  pia  mater  at  the  vertex,  apparently 
resulted  from  frequent  exposure  in  the  months  of  August  and 
September  bareheaded  to  the  sun's  rays. 

The  cause  of  tubercular  meningitis  need  not  detain  us.  It  is 
sufficiently  dwelt  upon  in  the  foregoing  pages. 

Premonitory  Stage. — Meningitis  is  usually  preceded  by  S3'mp- 
toms  which,  if  rightly  interpreted,  are  of  the  greatest  value.  In 
most  cases  of  both  the  simple  and  tubercular  forms,  which  I  have 
seen,  there  was  a  prodromic  period,  varying  from  a  few  days  to  as 


350  MENINGITIS,   SIMPLE    AND    TUBEECULAR. 

many  weeks.     The  symptoms  of  tliis  period  are  obscure,  and  are 
apt  to  be  mistaken  for  tbose  of  other  and  distinct  affections. 

The  chikl  in  whom  meningitis  is  approaching,  loses  his  accus- 
tomed vivacity  and  cheerfuhiess.  He  has  a  melancholy  and  sub- 
dued appearance,  being  quiet  for  a  few  minutes  and  then  fretful, 
without  apparent  cause.  He  can  sometimes  be  amused  by  his 
playthings  or  companions  for  a  brief  period,  when  he  turns  from 
them  with  evident  displeasure.  Unexpected  and  loud  noises  and 
bright  lights  are  evidently  painful.  If  old  enough  to  describe  his 
sensations,  he  complains  of  transient  dizziness,  and  at  other  times 
of  headache.  His  ill-humor,  if  his  wishes  are  not  immediately 
gratified,  or  if  they  are  denied,  is  often  scarcely  endurable  on  the 
part  of  friends  who  are  ignorant  of  the  cause.  There  is  great 
difference,  however,  in  different  cases,  as  regards  this  symptom. 
Some  are  inclined  to  be  taciturn  and  quiet,  while  others  are  almost 
constantly  fretting.  The  appetite  is  capricious ;  at  one  time  it  is 
pretty  good,  at  another  it  is  poor  or  even  entirely  lost.  The 
patient  may  take  a  few  mouthfuls  of  food,  or,  if  an  infant,  nurse 
for  a  moment,  when  his  hunger  appears  satisfied,  and  he  will  take 
nothing  more.  The  bowels  are  regular  or  inclined  to  constipa- 
tion. The  pulse  is  natural,  or  it  has  times  of  acceleration,  espe- 
cially in  the  latter  part  of  the  day  and  towards  the  close  of  the 
premonitory  stage.  The  duration  of  this  stage  is  very  different 
in  different  cases.  Upon  an  average  it  is  perhaps  about  two 
weeks,  but  it  is  often  longer.  In  tubercular  meningitis  the  symp- 
toms, both  during  the  inflammation  and  previously,  are  apt  to  be 
complicated  by  those  which  arise  from  tubercles  in  other  parts  of 
the  system. 

Unless  the  prodromic  period  is  of  short  duration,  the  effect  of 
imperfect  nutrition  is  obvious  before  it  closes.  The  flesh  becomes 
soft  and  flabby,  or  there  is  actual  emaciation,  though  generally 
slight.  The  patient  loses  his  strength,  becoming  less  able  to  stand 
or  to  walk,  and  more  easily  fatigued.  Occasionally,  especially  in 
the  simple  form,  premonitory  symptoms  are  absent,  or  are  slight 
and  of  short  duration. 

Symptoms. — Dr.  AVhytt,  living  in  the  last  century,  when  the 
tendency  was  rather  to  refinement  than  to  simplicity  in  classifica- 
tion, divided  meningitis  into  three  stages,  according  to  the  symp- 
toms, especially  the  pulse.  Many  subsequent  writers,  following 
Whytt's  example,  have  recognized  three  stages,  based  not  upon 
the  anatomical  character  of  the  disease,  but  upon  the  succession  of 
symptoms.     Such  division  of  meningitis  is  in  great  measure  arbi- 


SYMPTOMS.  851 

traiy,  since  in  one  case  the  same  symptom  occurs  at  an  earlier 
period  than  in  another. 

When  the  premonitory  stage  has  passed,  and  inflammation  is 
developed,  some  of  the  symptoms  which  were  previously  present 
remain  and  are  intensified,  and  other  new  and  more  characteristic 
symptoms  appear.  There  are  now  fewer  intervals  of  apparent 
improvement.  The  child  is  quiet,  often  lying  with  its  eyes  shut. 
If  aroused,  he  has  a  wild  expression  of  the  face,  and  is  irritated 
by  attempts  to  engage  his  attention  or  amuse  him.  He  rarely 
smiles,  or  takes  his  playthings,  or  he  notices  them  for  a  moment, 
when  he  turns  away  with  disgust.  During  sleep  there  is  often  at 
first  a  placid  expression  of  countenance,  but  when  aroused  he  has 
the  aspect  of  real  sickness;  the  eyebrows  are  sometimes  contracted, 
as  if  from  headache ;  the  features  wear  a  melancholy  look,  and  are 
turned  away  to  avoid  the  gaze  of  the  observer  or  to  shun  the  light. 
If  the  anterior  fontanelle  is  open,  it  is  observed  to  be  prominent 
and  pulsating  forcibly.  If  consciousness  is  not  lost,  and  the  patient 
is  of  sufficient  age,  he  complains  of  headache,  or  of  pain  in  some 
part  of  the  body.  The  tongue  is  moist,  and  covered  with  a  light 
fur;  the  appetite  is  lost  or  poor;  there  is  seldom  much  thirst; 
more  or  less  nausea  and  constipation  are  present.  As  the  inflam- 
mation continues,  and  usually  within  three  or  four  days  from  its 
commencement,  symptoms  arise  which  dispel  all  doubts,  if  there 
were  any,  as  to  the  nature  of  the  disease.  The  vital  powers  are 
now  evidently  beginning  to  yield.  The  surface  generally  is  more 
pallid,  and  there  is  the  curious  phenomenon  of  the  sudden  appear- 
ance, and,  after  some  minutes,  disappearance,  of  spots  or  patches, 
or  even  streaks  or  active  congestion  upon  the  face,  forehead,  or  the 
ears.  These,  having  a  bright  red  color,  contrast  strongly  with  the 
general  pallor.  Ordinarily  they  are  irregularly  circular  or  oval, 
and  from  one  inch  to  an  inch  and  a  half  in  diameter.  A  red  spot 
or  streak  is  also  produced  if  the  finger  is  pressed  upon  the  surface 
or  drawn  forcibly  across  it.  It  continues  a  few  minutes  and  then 
gradually  fades.  Trousseau  calls  attention  to  this  fact  as  a  diag- 
nostic sign. 

Another  curious  phenomenon  is  the  variation  in  temperature. 
The  face  and  limbs  at  one  time  feel  quite  cool,  and  after  some 
minutes,  without  any  excitement  or  other  appreciable  cause,  the 
temperature  rises,  so  that  the  surface  is  warm  to  the  touch. 

Consciousness,  in  severe  cases,  may  be  lost  at  an  early  period. 
On  the  other  hand,  I  have  known  it  in  a  case  of  moderate  severity 
to  remain,  though  partially  obscured,  till  within  twenty-four  or 


852  MENINGITIS,    SIMPLE    AND    TUBERCULAR. 

thirty-six  hours  of  death.  The  patient  will  usually  open  his  mouth 
for  drinks,  which  are  placed  to  his  lips,  when  there  is  no  other 
evidence  of  intelligence,  and  when  sight  and  hearing  are  evidently 
lost. 

The  loss  of  the  senses  constitutes  an  interesting  but  melancholy 
feature  of  the  disease.  Among  the  first  unequivocal  symptoms, 
and  frequently  the  very  first,  are  such  as  pertain  to  the  eye.  This 
organ  should  be  watched  from  day  to  day  when  the  diagnosis  is 
uncertain.  Deviation  from  its  normal  state  affords  evidence  of 
meningitis.  The  pupils  are  seen  to  dilate  or  contract  sluggishly 
by  variations  in  the  intensity  of  the  light,  or  they  are  not  of  the 
same  size  with  those  of  another  individual  to  whom  the  same 
amount  of  light  is  admitted.  Sometimes  the  first  perceptible  devia- 
tion from  the  normal  state  is  an  inequality  in  the  size  of  the  pu- 
pils; while  in  others  oscillation  of  the  iris  is  observed.  At  a  later 
stage,  not  generally  till  convulsions  have  occurred,  the  parallelism 
of  the  eyes  is  lost,  and  in  most  patients  they  have  an  upward  direc- 
tion. After  efiusion  has  occurred,  the  pupils  are  commonly  dilated. 
As  death  approaches,  the  eyes  become  bleared,  and  a  puriform  se- 
cretion collects  in  the  inner  angle  of  the  eye  and  between  the  eye- 
lids. This  secretion  is  not  abundant,  but  it  is  sometimes  sufficient 
to  unite  the  lids.  The  sense  of  hearing  is  probably  lost  as  soon, 
or  nearly  as  soon,  as  that  of  sight,  but  the  sense  of  touch  continues 
longer.  The  tongue  is  covered  with  a  moist  fur,  unless  near  the 
close  of  life,  when  it  is  sometimes  dry.  The  appetite  is  gradually 
lost,  but  often  drinks  are  taken  with  apparent  relish,  even  when 
there  is  no  other  evidence  of  consciousness.  There  are  two  symp- 
toms pertaining  to  the  digestive  system  which  are  rarely  absent, 
and  which  possess  great  diagnostic  value ;  one  is  vomiting,  the 
other  constipation.  In  some  patients,  irritability  of  stomach  begins 
at  so  early  a  period  that  it  is  really  prodromic;  it  is  rarely  absent. 
Barrier  collected  the  records  of  eighty  cases  of  meningitis,  in 
seventy-five  of  which  this  symptom  was  recorded  present.  It  is 
due  to  the  intimate  relation  existing  between  the  stomach  and 
brain,  through  the  ganglionic  system  of  nerves.  The  vomiting 
occurs  without  effort,  and  usually  at  intervals,  for  several  days.  It 
is  a  sudden  ejection  of  the  contents  of  the  stomach,  apparently 
without  preceding  or  subsequent  nausea.  It  contrasts,  therefore, 
with  the  vomiting  due  to  an  emetic,  which  is  attended  by  distress- 
ing symptoms.  AVith  some  it  occurs  frequently,  with  others  not 
more  than  two  or  three  times  daily.  Commencing  in  the  first 
stages  of  meningitis,  or  even  prior  to  it,  it  occurs  less  often  as  the 


SYMPTOMS.  353 

drowsiness  becomes  more  profound,  and  finally  ceases.  Constipa- 
tion is  also  present,  usually  from  the  commencement  of  the  disease. 
It  is  one  of  the  most  constant  and  persistent  symptoms,  continuing 
through  the  entire  sickness,  unless  relieved  by  medicine,  or  unless 
there  is  a  coexisting  diarrhoeal  aft'ection.  Often,  when  diarrhoea 
precedes  the  meningitis,  it  ceases  the  moment  the  latter  commences. 
The  constipation  in  this  disease  is  easily  overcome  by  purgatives. 
Several  writers  speak  of  retraction  of  the  abdomen  as  a  sign  of 
meningitis.  A  hollow  or  sunken  appearance  of  the  abdomen, 
according  to  Golis,  aids  in  distinguishing  meningitis  from  fever. 
The  anterior  abdominal  wall  approaches  the  spine,  so  that  the  pul- 
sations of  the  abdominal  aorta  are  distinctly  felt.  Rilliet  and  Bar- 
thez,  who  have  rarely  observed  this  retraction  except  in  cerebral 
diseases,  attribute  it  to  the  state  of  the  intestines  rather  than  to 
the  action  of  the  abdominal  muscles. 

The  pulse  in  the  first  stages  of  meningitis  is  accelerated,  or  it  is 
nearly  natural  during  certain  hours  and  afterwards  accelerated. 
When  the  disease  has  continued  a  few  days,  often  not  more  than 
three  or  four,  the  pulse  undergoes  a  marked  change.  It  becomes 
slower  and  at  the  same  time  irregular.  The  irregularity  usually 
consists  in  an  intermittence  of  the  pulse  after  each  six  or  eight 
beats.  Sometimes  the  force  of  the  pulse  varies,  so  that  a  feeble 
pulsation  is  succeeded  by  one  of  greater  volume  and  strength.  The 
decrease  in  the  frequency  of  the  pulse  cannot  fail  to  arrest  atten- 
tion. From  110  or  120  beats  per  minute  in  the  first  stage  of  the 
inflammation  it  often  descends  to  a  frequency  even  less  than  the 
normal  adult  pulse.  At  an  advanced  period,  as  death  approaches, 
the  pulse  again  becomes  accelerated  and  feeble. 

The  change  in  respiration  is  as  decided  as  that  of  the  pulse.  In 
the  beginning  of  the  meningitis  respiration  is  sometimes  mode- 
rately accelerated,  but  in  other  cases  it  is  natural.  When  the 
disease  has  continued  a  few  days,  the  time  usually  varying  from 
three  or  four  to  more  than  a  week,  a  marked  alteration  occurs  in 
the  respiratory  movements.  Their  rhythm,  like  that  of  the  pulse, 
is  disturbed.  The  breathing  is  irregular,  intermittent,  and  accom- 
panied by  sighs.  Tiiis  change  in  pulse  and  respiration  corresponds 
with  the  loss  of  consciousness,  and  shows  that  the  brain  is  becoming 
seriously  involved. 

When  the  pulse  and  respiration  undergo  the  changes  which  have 

been  described,  another  prominent  and  grave  cerebral  symptom  is 

often   present,   namely,  convulsions.      Its   occurrence   diminishes 

greatly  the  prospect  of  a  favorable  issue.     The  severity  and  extent 

23 


354  MENINGITIS,    SIMPLE    AND    TUBERCULAR. 

of  the  convulsive  movements  vary  in  different  cases.  They  may 
he  partial  or  general.  Their  duration  is  often  hrief,  hut  they 
recur  three  or  four  times  through  the  day.  They  are  preceded  by 
cephalalgia  in  those  old  enough  to  express'  their  sensations,  and 
often  by  drowsiness.  Each  convulsive  attack  ends  in  still  greater 
drowsiness. 

With  this  group  of  symptoms  another  should  be  mentioned,  I 
refer  to  the  hydrocephalic  cry.  At  intervals  the  patient,  without 
being  disturbed,  and  without  any  change  in  symptoms,  utters  a 
scream  or  sharp  cry,  and  immediately  relapses  into  his  former 
state.  This  cry  is  more  common  in  the  first  stages  of  the  disease 
than  subsequently,  and  in  some  it  is  absent  or  is  not  a  marked 
symptom.  The  glandular  system  participates  in  the  general  loss 
or  derangement  of  function.  Tears  are  seldom  shed,  even  when 
the  child  is  much  irritated,  and  the  urinary  secretion  is  greatly 
diminished.  The  small  amount  of  urine  passed  sustains  an  im- 
portant relation  to  the  progress  of  the  disease  and  the  therapeutics. 

The  patient  usually  lingers  several  days  after  the  pulse  and 
respiration  are  changed  in  the  manner  stated.  The  drowsiness 
becomes  more  profound,  the  vomiting  ceases,  as  well  as  the  con- 
vulsive attacks,  and  sensation  and  consciousness  are  entirely  lost. 
But  even  in  this  state,  if  nutriment  and  stimulants  are  adminis- 
tered with  regularity,  the  child  often  lives  several  days  longer 
than  the  friends  believed  to  be  possible.  At  length  increasing 
feebleness  and  rapidity  of  pulse  and  coldness  of  the  face  and  limbs 
indicate  the  near  approach  of  death,  which  occurs  in  a  state  of 
coma. 

The  symptoms  described  above  are  such  as  occur  in  ordinary 
cases  of  meningitis,  and  in  the  order  which  I  have  indicated.  But 
he  will  be  disappointed  who  expects  that  the  above  description 
will  apply  to  all  cases. 

Meningitis  may  be  so  violent  and  rapid  that  both  the  charac- 
ter and  succession  of  symptoms  are  different  from  those  which 
have  been  stated.  Thus,  I  have  related  the  case  of  a  girl,  who, 
with  no  prodromic  symptoms  excepting  occasional  dizziness  and 
slight  headache,  was  taken  sick  on  Thursday,  had  convulsions  on 
Friday,  and  from  this  time  continued  either  in  convulsions  or 
coma  till  her  death  on  Monday.  Again,  even  in  cases  of  the  usual 
duration  and  anatomical  character,  some  of  the  most  prominent 
symptoms  upon  which  we  rely  for  diagnosis  may  be  lacking.  The 
following  was  a  case  of  this  kind: — 


s  Y  M  r  T  o  iM  s .  355 

Case. — On  the  5th  of  April,  18G2, 1  was  asked  to  see  a  bo}' two  years  and 
eight  inontlis  old,  of  henltliy  parentage,  and  who,  during  the  preceding 
year,  had  been  in  unilbrni  good  health,  but  previously  had  had  two  or 
three  severe  attacks  of  sickness,  llis  head  was  of  large  size,  and  when- 
ever much  indisposed  he  usuall}'  had  symptoms  premonitory  of  convul- 
sions, which  were  always,  however,  prevented. 

One  night,  in  the  latter  part  of  March,  his  parents  noticed  that  his 
sleep  was  restless,  but  on  the  following  day  he  seemed  entirely  well, 
and  the  restlessness  at  night  was  attributed  to  a  late  and  hearty  supper. 
On  succeeding  nights,  however,  he  was  restless,  and,  when  questioned, 
complained  of  pain  in  the  abdomen.  In  a  few  days  he  was  observed  to 
be  drooping  in  the  daytime,  and  his  appetite  was  not  quite  so  good  as 
previonsl}'.  lie  had  continued  in  this  way  about  a  week  when  my  first 
visit  was  made. 

The  abdominal  pain  had  at  this  time  become  more  constant,  but  was 
never  severe  or  accompanied  by  moaning.  When  asked  where  he  felt 
sick,  he  placed  his  hand  upon  the  epigastrium,  pressure  upon  which  was 
sometimes  tolerated,  but  at  other  times  painful.  The  following  symp- 
toms were  noted:  tongue  slightly  furred,  anorexia,  thirst,  constipation, 
scantiness  of  urine,  no  headache  or  unusual  heat  of  head  in  an}'  part 
of  his  sickness.  He  vomited  at  intervals  from  about  the  seventh  to  the 
tenth  of  April,  when  the  irritability  of  stomach  ceased,  and  there  was 
no  return  of  this  symptom. 

About  April  7th,  the  respiration  was  first  observed  to  be  irregular 
and  sighing,  and  the  pulse  intermittent.  These  symptoms,  so  tardily 
developed,  were  the  first  which  indicated  cerebral  disease.  He  now  lay 
most  of  the  time  in  bed,  Avith  e3'es  closed,  surface  commonly  pale,  with 
occasional  rose-colored  spots  or  patches  upon  the  cheek  or  forehead. 
The  pupils  responded  to  light  in  the  usual  manner  till  near  the  close  of 
life,  but  bright  lights  were  painful;  the  last  two  or  three  days  of  his 
life  the  left  pupil  was  more  dilated  than  the  right.  He  had  no  convul- 
sions or  any  spasmodic  movement,  and  was  conscious  till  within  a 
few  hours  of  death ;  the  mother  states  that  there  was  unequivocal 
evidence  of  his  recognition  of  her  on  the  last  day  of  his  life.  He  died 
April  nth,  nearly  three  weeks  after  the  commencement  of  the  disease, 
and  ten  days  after  the  commencement  of  symptoms  which  were  dis- 
tinctly referable  to  the  cerebro-spinal  sj^stem. 

AutoiDsy. — Abdominal  organs  healthy,  though  epigastric  pain  had  been 
so  constant  and  prominent  a  symptom ;  brain  and  its  membranes  some- 
what injected.  The  meninges  covering  the  base  of  the  brain  from  the 
most  prominent  part  of  the  pons  Varolii  to  the  first  pair  of  nerves  pre- 
sented evidences  of  inflammation.  There  was  such  opacity  of  the  pia 
mater  in  places,  as  to  conceal  the  brain  from  view.  The  anterior  and 
middle  lobes  of  each  hemisphere  were  glued  together  by  fibrinous 
exudation,  and  on  the  left  side,  along  the  fissure  of  Sjdvius,  was  a  thick 
deposit  of  the  same  character.  The  lateral  ventricles  contained  about 
an  ounce  of  clear  serum,  and  about  half  an  ounce  escaped  from  the  base 
of  the  brain.  The  foramen  of  Monro  was  considerably  enlarged,  and 
the  brain-substance  surrounding  the  lateral  ventricles  was,  perhaps, 
somewhat  softened,  but  not  in  a  notable  degree. 

In  this  case  it  is  seen  that  the  prominent  symptom,  and,  indeed, 
almost  the  only  marked  symptom  in  the  first  stages  of  the  disease, 
was  pain  in  the  abdomen,  and  yet  the  abdominal  organs  were 


856  MENINGITIS,    SIMPLE    AND    TUBERCULAR. 

healthy.  At  the  very  moment  when  it  was  highly  important  that 
a  correct  diagnosis  should  be  made,  the  evidences  of  cerebral  dis- 
ease were  lacking.  This  case  is,  therefore,  interesting  on  account 
of  the  variation  in  symptoms  from  those  in  the  usual  form  of 
menino'itis.  There  were  no  convulsions,  and  consciousness  was 
retained  as  well  as  vision  till  near  the  close  of  life,  and  yet  the 
lesions  were  such  as  are  commonly  present  in  meningeal  inilamma-  ^ 
tion.  In  such  cases  a  wrong  diagnosis  is  apt  to  be  made,  to  the 
injury  of  the  patient  and  the  reputation  of  the  physician. 

Occasionally  meningitis  may  continue  so  long  as  to  almost  justify 
its  being  called  chronic,  even  when  there  is  a  lai^ge  amount  of 
exudation  upon  the  pia  mater.  In  meningitis  which  terminates 
favorably,  there  is  a  gradual  subsidence  of  symptoms.  I  shall 
describe  more  fully  this  termination  in  speaking  of  prognosis. 

Diagnosis. — It  is  of  the  utmost  importance  to  diagnosticate 
meningitis  in  its  first  stages,  since  treatment,  to  be  successful,  must 
be  commenced  early.  Some  writers  describe  at  length  the  means 
of  diagnosticating  the  simple  from  the  tubercular  form  of  the 
disease.  Differential  diagnosis  is  often  difficult,  and  sometimes 
impossible;  but  it  matters  little,  practically,  whether  the  form  of 
the  disease  is  ascertained.  On  the  other  hand,  it  is  very  important, 
in  order  that  the  treatment  be  appropriate,  to  diagnosticate  the 
premonitory  or  initial  stage  of  meningitis  from  certain  other 
affections  not  located  within  the  cranium.  Sometimes  remittent 
or  continued  fever,  or  constitutional  disturbances  arising  from 
irritation  in  the  digestive  system,  simulate  closely  incipient  me- 
ningeal disease,  so  that  the  greatest  care  and  discrimination  are 
a^equired  in  order  to  make  a  correct  diagnosis.  AVithin  a  compara- 
tively recent  period  I  have  known,  in  three  different  instances, 
■experienced  physicians  of  this  city  mistake  commencing  meningitis 
for  fevers,  not  aware  of  the  serious  error  they  had  made  till  the 
inflammation  had  reached  a  stage  from  which  recovery  was  impos- 
sible. In  order  to  make  a  correct  diagnosis  in  the  premonitory  or 
initial  stage  of  meningitis,  the  physician  should  take  time  to 
observe  the  physiognomy,  and  note  every  symptom.  More  than 
one  protracted  visit  is  often  required  to  remove  all  doubt  as  to  the 
exact  pathological  state. 

Meningitis  ifi  usually  preceded  and  in  its  commencement  accom- 
panied l>y  great-er  restlessness,  fretfulness,  intolerance  of  light, 
and  greater  variation  of  symptoms  than  most  other  diseases.  One 
familiar  with  the  physiognomy  of  infancy  and  childhood,  will 
discover  in  the  features  indication  of  greater  suffering,  of  more 


PROGNOSIS.  357 

serious  sickness,  than  is  commonly  present  in  other  aiul  distinct 
affections  whose  symptoms  are  similar. 

Sometimes  the  snddcn  disappearance  of  a  chronic  eruption  npon 
the  scalp  will  aid  in  the  diagnosis.  This  is  a  sign  of  importance, 
taken  in  connection  with  the  symptoms.  Headache  and  vomiting, 
symptoms  of  early  occurrence,  should  especially  arrest  attention, 
or,  in  absence  of  headache,  pain  of  a  neuralgic  character  in  some 
other  part.  If  there  is  doubt  at  first,  careful  and  repeated  exami- 
nations, if  we  are  familiar  with  the  various  signs  and  symptoms  of 
meningitis,  will  soon  remove  all  uncertainty.  When  the  eyes 
become  aifected,  the  respiration  and  circulation  irregular,  and 
especially  when  convulsive  attacks  begin,  diagnosis  is  eas}^.  In 
fact,  an  incorrect  diagnosis  would  then  be  unpardonable;  but, 
unfortunatel}'-,  if  proper  treatment  has  not  been  commenced  till 
this  period,  it  will  be  of  little  service. 

Prognosis. — Meningitis  is  one  of  the  most  fatal  diseases  of  early 
life.  Whether  the  form  is  simple  or  tubercular,  if  the  initial  stage 
has  passed  without  proper  treatment,  death  may  be  considered 
inevitable.  Tubercular  meningitis,  however  early  recognized,  is 
rarely  amenable  to  treatment.  M.  Guersant  {Die.  Med..,  t.  xix.  p. 
403)  believes  that  recovery  from  the  first  stage  of  tubercular 
meningitis  is  possible.  "In  the  second  stage,"  says  he,  "I  have 
not  seen  one  child  recover  out  of  a  hundred,  and  even  those  who 
seemed  to  have  recovered  have  either  sunk  afterwards  under  a 
return  of  the  same  disease  in  its  acute  form,  or  have  died  of 
phthisis.  As  to  patients  in  whom  the  disease  has  reached  its  third 
stage,  I  have  never  seen  them  improve  even  for  a  moment."  The 
very  few  reported  cases  which  resulted  favorably  may  have  been, 
as  M.  Gruersant  has  intimated  in  the  context,  cases  of  the  simple 
form.  Rilliet  and  Barthez  believe  that  in  a  few  instances  tuber- 
cular meningitis  has  been  cured  in  its  first  stages,  but  they  state 
also  that  the  disease  is  apt  to  return. 

The  prognosis  in  simple  meningitis  is  not  so  unfavorable,  pro- 
vided treatment  is  commenced  at  a  sufiiciently  early  period.  It 
is  now  generally  admitted  that  the  simple  form  may  not  infre- 
quently be  averted,  when  threatening,  and  even  arrested  in  its 
incipiency.  In  many  such  cases  we  cannot,  from  the  nature  of  the 
disease,  be  certain  that  the  diagnosis  is  correct.  But  when  we  see 
children  relieved,  who  present  precisely  those  premonitory  and  even 
initial  symptoms  which  occur  in  meningitis,  we  must  believe  that 
at  least  some  of  them  would  have  had  the  genuine  disease  if  not 
relieved  by  the  measures  employed.     That  recovery  is  possible  from 


3-3S  MEXIXGITIS,    SIMPLE    AXP    TUBERCULAR. 

simple  menhiiritis  in  its  commenoomont,  is  also  obvious  from  the 
fact  that  a  few  recover  eveu  from  the  advanced  stage,  when  there 
can  he  no  error  of  diagnosis. 

I  have  known  but  two  recoveries  from  meningitis  when  it  had 
continued  so  long  and  had  reached  that  degree  that  the  function 
of  the  brain  and  cmnial  nerves  was  impjiired.  One  of  these  re- 
covered with  the  permanent  loss  of  sight,  the  other  with  the  loss 
of  hearinir.  Both  seem  to  have  ordinary  intelligence.  Another 
case  has  been  communicated  to  me.  in  which  the  jxitient,  a  little 
girl,  recovered  completely,  but  for  several  months  after  the  attack 
seemed  nearly  idiotic. 

Sometimes  even  in  the  second  stage  of  meningitis,  treatment 
properly  employed  is  attended  by  amelioration  of  symptoms. 
Though  such  improvement  may  serve  to  encourage  physician  and 
friends,  it  should  not  be  the  basis  of  a  favorable  prognosis  unless 
it  continue  three  or  four  days. 

Apparent  improvement  during  a  few  houi"s  or  a  considerable 
part  of  a  day  is  not  unusual  in  those  who  Unally  die.  Thus,  in 
an  infiint  whose  bowels  were  previously  confined,  I  have  known 
the  pulse  and  respiration  to  become  more  regular  and  the  symp- 
toms generally  improve,  though  only  for  a  brief  period,  by  the 
action  of  a  purgative.  Dr.  AVatson  says  of  the  advanced  stages 
of  this  disease,  it  is  "  often  attended  with  remissions,  sometimes 
sudden,  and  sometimes  gradual,  deceitful  appearances  of  conva- 
lescence. The  child  reo^ains  the  use  of  its  senses,  recoornizes  those 
about  him  again,  appears  to  his  anxious  parents  to  be  recovering, 
but  in  a  day  or  two  it  relapses  into  a  state  of  deeper  coma  than 
before.  And  these  tallacious  symptoms  of  improvement  may  occur 
more  than  once." 

Most  fatal  cases  of  meninoritis  terminate  between  the  third  or 
fourth  and  the  twentieth  dav,  the  duration  varvinff  accordiu!?  to 
the  extent  and  intensitv  of  the  inflammation,  and  the  vio^or  and 
age  of  the  patient.  But  there  are  cases  in  which  it  may  continue 
much  longer.  It  is  surprising  sometimes  how  long  the  patient 
lives,  when  the  symptoms  are  such  that  death  seems  impending. 
Sensation  and  consciousness  mav  be  extiuijuished,  convulsions  occur 
at  intervals,  and  the  surface  have  acquired  almost  a  cadaveric 
aspect,  and  yet  the  patient  lives  on.  Rilliet  and  Barthez  say, 
"Often  have  we  inscribed  upon  our  notes  death  iynmhient,  and  been 
astonished  the  next  day  to  find  still  alive  children  to  whom  we 
had  scarcely  allowed  two  houi-s  of  life."  The  symptom  which  I 
have  found  to  be  the  most  reliable  prognostic  of  the  near  approach 


TREATMENT.  3o9 

of  death,  has  been  a  pulse  gradually  becoming  more  frequent  and 
feeble,  though  other  symptoms  remain  as  before.  This  change  in 
the  pulse  is  usually  very  apparent  during  the  last  twenty-four  hours 
of  life. 

Treatment. — Such  remedial  measures  should  be  prescribed  during 
the  premonitory  stage  as  are  calculated  to  relieve  the  fretfulness 
or  irritability  of  temper,  and  quiet  the  action  of  the  brain,  and, 
at  the  same  time,  produce  a  derivative  effect  from  this  organ.  To 
this  end  the  jjatient  should  be  kept  from  all  causes  of  excitement, 
and  the  bowels  should  be  opened  daily,  if  not  naturally,  by  the  use 
of  proper  medicines.  A  mustard  foot-bath  at  night  and  occasion- 
ally through  the  day  is  useful,  as  it  produces  both  a  derivative  and 
soothing  effect.  It  will  commonly  produce  a  few  hours'  undis- 
turbed rest,  w^iile  all  other  measures  except  medicine  fail.  If  den- 
tition is  taking  place  and  the  gums  are  swollen,  it  is  sometimes  pro- 
per to  scarify  them.  This  operation,  by  diminishing  the  swelling 
and  tenderness,  may  diminish  the  irritability  of  system.  In  most 
cases  in  which  there  are  symptoms  threatening  meningitis,  mode- 
rate counter-irritation  behind  the  ears  is  required.  The  fact  that 
the  disease  sometimes  follows  the  recession  of  cutaneous  eruptions 
of  the  scalp  shows  the  importance  of  this  remedy ;  but  it  is  not 
advisable  to  produce  counter-irritation  over  a  large  surface,  since 
this  may  increase  the  restlessness  of  the  child,  and  aggravate 
rather  than  relieve  the  state  of  the  head.  West  says:  "Another 
inquiry  that  you  may  put  is,  wdien  are  you  to  employ  blisters? 
Certainly  not  at  the  beginning  of  the  disease,  when  they  would 
increase  the  general  irritation,  and  do  more  harm  than  good.  At 
a  later  period  they  may  be  of  service,  when  the  excitement  is 
about  to  yield  to  that  stupor  which  usually  precedes  the  state  of 
complete  coma.  They  should  then  be  applied  to  the  nape  of  the 
neck  or  to  the  vertex."  Vesication  produced  at  so  late  a  period  as 
Dr.  West  recommends,  can  produce  little  effect  in  arresting  the 
disease ;  besides,  counter-irritation  at  the  vertex  or  back  of  the 
neck  is  too  far  removed  from  the  seat  of  the  disease.  I  have  never 
known  it,  when  employed  in  the  manner  which  I  shall  advise,  to 
increase  the  restlessness.  I  have  many  times  prescribed  vesication — 
Bometimes  when  the  symptoms  passed  off  and  there  was  restoration 
to  health;  at  other  times,  when  meningitis  supervened  with  its 
usual  result — and  I  have  never  regretted  the  prescription.  Cantha- 
ridal  collodion  applied  with  a  brush  answers  the  purpose,  and  from 
the  convenience  of  its  application  is  to  be  preferred.  It  does  not  vesi- 
cate deeply,  or  produce  a  troublesome  sore.    If  symptoms  indicating 


360  MENINGITIS,    SIMPLE    AND    TUBERCULAR. 

the  approach  of  meningitis  continue,  iodide  of  potassium  should  be 
given  in  decided  doses.  We  will  speak  more  of  this  in  our  re- 
marks on  the  treatment  of  the  disease. 

Many  children  who  are  threatened  with  meningitis  are  scrofulous. 
They  have  already  shown  symptoms  of  tubercular  disease.  They 
are,  perhaps,  to  a  certain  extent,  emaciated,  and  may  have  been 
aitected  with  a  cough.  The  premonitory  symptoms  in  these  chil- 
dren indicate  the  approach  of  the  tubercular  form  of  meningitis, 
and  a  more  sustaining  course  of  treatment  is  required  than  in  those 
who  are  robust.  To  such  children  cod-liver  oil  may  be  profitably 
given,  three  times  daily,  together  with  the  syrup  of  the  iodide  of 
iron,  or  iodide  of  potassium.  They  should  also  be  taken  into  the 
open  air,  with  proper  precautions,  and  every  hygienic  measure 
should  be  employed  which  will  be  likely  to  invigorate  the  system 
without  exciting  the  brain. 

Loss  of  blood  is  not,  in  general,  required  during  the  prodromic 
period  nor  in  the  disease.  Those  of  a  strumous  cachexia,  or  those, 
whether  strumous  or  not,  who  are  under  the  age  of  two  years,  do 
not,  unless  in  very  rare  instances,  require  depletion  by  leeches, 
much  less  by  venesection.  There  is  one  class  of  patients  in  whom 
the  early  loss  of  blood  may,  doubtless,  be  of  service,  namely,  those 
who  in  a  state  of  robust  health  are  suddenly  seized  with  the  in- 
flammation. Leeches  should  then  be  applied  to  the  head  of  the 
patient,  if  he  is  seen  at  an  early  period. 

The  propriety  of  using  opium  to  allay  irritability  of  system  in 
those  threatened  with  meningitis  is  viewed  diiierentl}'-  by  physi- 
cians. Bouchut  says :  "  Opiates  have  the  inconvenience  of  increas- 
ing constipation,  but  they  are  very  useful  in  calming  the  state  of 
cerebral  excitement  of  young  infants.  Laudanum  should  be  given 
in  a  draught  in  a  narcotic  dose,  at  short  intervals,  gradually  in- 
creasing the  dose  of  it  until  sleep  is  obtained."  I  prefer,  in  order 
to  relieve  the  restlessness,  the  use  of  hydrate  of  chloral.  From 
one  to  three,  or  even  five,  grains  may  be  given,  and,  if  necessary, 
repeated  after  some  hours. 

Often,  notwithstanding  the  measures  employed,  the  patient  grows 
worse,  the  symptoms  become  more  continuous,  others  more  alarm- 
ing arise,  and  meningitis  declares  itself.  For  internal  treatment, 
there  are  two  medicines  which  are  extensively  used  by  the  pro- 
fession— in  fact,  to  the  exclusion  of  nearly  all  others — the  one  calo- 
mel, the  other  iodide  of  potassium.  Those  who  employ  the  iodide 
as  the  main  remedy,  commonly  also  prescribe  single  doses  of  calo- 
mel occasionally,  as  an  eligible  purgative  when  there  is  constipa- 


TREATMENT.  3G1 

tioii,  SO  that  half  a  dozen  or  more  doses  may  be  given  in  the  course 
of  the  disease.  By  those  who  depend  upon  cak^mel  as  the  main 
remedy,  it  is  given  not  only  to  keep  up  a  relaxed  state  of  the  bowels, 
but  also  in  the  belief  that  it  arrests  the  exudation  from  the  menin- 
ges.    These  last  give  it  daily  in  small  doses. 

My  observations  have  not  been  favorable  to  the  use  of  calomel, 
except  as  an  occasional  purgative.  When  administered  dail}',  it 
has  a  very  depressing  eflect,  and  it  is  to  be  recollected  that  this  is 
a  disease  in  which  the  vital  powers  rapidly  sink  in  consequence 
of  the  loss  of  appetite  and  the  frequent  vomiting.  In  tubercular 
meningitis,  it  is  obvious  that  any  remedy  which  greatly  reduces 
the  strength  may  promote  the  formation  of  tubercles,  and  thereby 
diminish  the  chances  of  recovery.  Cases  have  occurred  in  which 
calomel  was  given  at  short  intervals  for  several  successive  days, 
and  though  the  meningitis  seemed  to  be  relieved,  death  resulted 
from  sheer  exhaustion  or  from  some  intercurrent  affection,  the 
result  of  exhaustion,  or  of  the  remedy.  In  one  case  related  to  me, 
fatal  gangrene  of  the  mouth,  the  result  of  the  mercurial  treatment, 
supervened  after  the  meningitis  had  apparently  subsided.  Unless, 
therefore,  statistics  show  that  a  larger  proportion  recover  by  the 
use  of  calomel  than  by  iodide  of  potassium,  we  should  prefer  the 
safer  agent.  I^ow,  while  certain  patients  recover  who  exhibit 
symptoms  which  are  premonitory  of  meningitis,  and  a  few  from 
meningitis  itself,  by  the  use  of  iodide  of  potassium,  restoration  to 
health  by  the  calomel  treatment  is  certainly  very  rare,  if  there 
are  unequivocal  evidences  of  meningeal  inflammation.  Dr.  Whytt, 
who  lived  in  the  time  when  calomel  and  loss  of  blood  were  com- 
monly prescribed  not  only  in  this  but  in  other  diseases,  never  saw 
a  favorable  case.  Moreover,  physicians  of  the  present  time  incline 
more  and  more  to  the  use  of  iodide  of  potassium,  and  the  rejection 
of  calomel,  as  the  main  remedy. 

The  iodide  of  potassium  should  be  given  early  in  the  premonitory 
period.  If,  by  a  careful  examination,  the  absence  of  any  other 
local  disease  or  of  a  constitutional  aifection  which  might  give  rise  to 
similar  symptoms  is  ascertained,  this  agent  should  immediately  be 
prescribed.  The  symptoms  at  this  early  period  are  often  so  obscure 
that  a  positive  diagnosis  cannot  be  made ;  but  it  is  better  to  give 
the  iodide  even  if  the  diagnosis  is  wrong,  and  no  meningeal  disease 
is  threatening,  than  to  err  on  the  other  side  and  withhold  its  use 
in  the  prodromic  and  initial  period  of  the  true  disease.  An  infant 
from  six  to  twelve  months  old  should  take  two  grains  every  two 
hours,  and  older  children  a  proportionate  dose.     Larger  doses  may 


862  MENINGITIS,    SIMPLE    AND    TUBERCULAR. 


in  some  cases  be  administered.  "When  thus  given,  the  iodide  soon 
produces  an  impression  on  the  system,  and  especially  on  the  renal 
secretion,  the  quantity  of  urine,  previously  scanty,  being  largely 
increased.  If  with  the  regular  and  continued  use  of  potassium 
there  is  no  improvement,  the  case  is  without  remedy. 

Throughout  the  disease,  as  well  as  in  its  commencement,  the 
iodide  of  potassium  should,  therefore,  be  employed  until  it  is  obvi- 
ous that  there  is  no  chance  whatever  of  improvement,  when  medi- 
cation may  proj^erly  be  discontinued.  The  best  remedy  for  the 
convulsions  which  sooner  or  later  occur  in  most  cases,  is  hydrate  of 
chloral  given  in  small  doses.  The  apartment  should  be  dark  and 
quiet ;  a  moderate  degree  of  vesication  should  be  produced  behind 
the  ears,  and  the  head  be  kept  cool.  In  simple  meningitis  occur- 
ring in  children  three  or  four  years  of  age  or  older,  previously 
healthy  and  robust,  it  is  proper  to  place  a  bladder  with  pounded 
ice  over  the  head,  separated  perhaps  by  two  or  three  thicknesses  of 
muslin,  provided  that  the  temperature  is  elevated,  as  it  ordinarily 
is.  If  there  is  not  much  heat,  or  if  the  child  is  considerably  pros- 
trated, a  cloth  wrung  out  of  cool  water  will  be  sufficient.  Bouchut 
recommends  irrigation,  and  condemns  the  mode  of  applying  cold 
which  is  recommended  above.  Says  he,  "  Refrigerants  external  to 
the  cranium  are  often  employed,  and  their  use  appears  very  ra- 
tional ;  still  they  do  not  possess  a  very  great  efficacy.  The  appli- 
cation of  compresses  moistened  with  cold  water,  ice  in  a  bladder 
and  laid  on  the  forehead,  are  bad  remedies,  which,  by  causing  too 
considerable  alternations  of  heat  and  cold,  are  rather  noxious  than 
useful  to  the  child.  If  it  is  wished  to  employ  refrigerants,  recourse 
should  be  had  to  continual  irrigation.  The  patient  is  not  to  be 
disturbed  in  its  bed;  the  head  should  be  placed  on  a  cushion,  the 
hair  being  cut  very  short ;  the  neck  is  bound  moderately  tight  by 
an  impermeable  stuff,  so  placed  on  each  side  as  to  form  a  gutter,  so 
that  the  water  which  has  been  used  in  the  irrigation  can  run  off 
from  each  side  of  the  bed  without  wetting  the  body  of  the  child. 
Having  arranged  these,  a  jar  filled  with  water  of  a  moderate  tem- 
perature, 64°  Fahr.,  is  placed  above  the  patient;  a  siphon  with  a  tap 
is  to  be  placed  in  the  jar,  to  moderate  at  will  the  flow  of  the  liquid. 
To  this  tap  is  fastened  a  skein  of  loose  thread  for  the  purpose  of 
conducting  the  water  to  the  forehead,  so  as  to  avoid  the  continuous 
dropping  of  the  liquid,  which  would  be  insupportable."  If,  how- 
ever, there  is  an  attentive  nurse,  who  renews  the  wet  cloth  suffi- 
ciently often,  there  does  not  seem  to  be  any  danger  from  reaction, 
as  feared  by  Bouchut.     Irrigation  requires  as  constant  attention, 


1 


SPURIOUS    HYDROCEPHALUS.  3(33 

in  consequence  of  the  restlessness  of  the  child,  as  does  the  treat- 
ment by  a  wet  cloth,  in  order  that  there  be  no  interruption  in 
the  employment  of  it.  Few  children  will  remain  quiet  with  a 
descent  of  water  upon  the  head,  except  those  who  have  become 
entirely  insensible,  and  in  such  neither  a  wet  cloth  nor  irrigation 
aftbrds  any  material  benefit.  In  simple  meningitis  in  its  first 
stages,  the  diet  should  be  mild  and  rather  scanty ;  in  the  tubercular 
form  it  should  be  more  nourishing;  beef-tea  and  milk-porridge  are 
required.  In  both  the  simple  and  tubercular  form,  at  an  advanced 
stage,  the  most  nourishing  food  is  required,  but  stimulants  should 
not  be  given  unless  near  the  close  of  life,  when  the  vital  powers  are 
failing. 


CHAPTER  X. 

SPURIOUS  HYDROCEPHALUS. 

The  disease  known  as  spurious  hydrocephalus  might  with  more 
propriety  be  called  spurious  meningitis.  It  received  its  appella- 
tion at  the  time  when  meningitis  of  early  life  was  believed  to  be 
essentially  a  hydrocephalus,  and  was  so  called.  Attention  was 
first  directed  to  this  affection  by  London  physicians  of  the  last 
generation,  particularly  Drs.  Gooch,  Abercrombie,  and  Marshall 
Hall,  and  little  can  be  added  to  their  description  of  its  symptoms. 

Anatomical  Characters. — This  disease,  though  resembling  me- 
ningitis in  certain  of  its  phenomena,  is  not  in  its  nature  inflam- 
matory, nor  is  it  primary.  It  is  the  result  of  some  affection  often 
chronic,  but  occasionally  acute,  which  has  produced  exhaustion, 
especially  of  the  nervous  system.  When  it  commences,  there  is 
usually  more  or  less  emaciation,  and  the  symptoms  of  the  primary 
disease  are  present.  To  this  disease  the  lesions  pertain  which  are 
found  in  other  organs  besides  the  brain. 

The  state  of  the  brain  in  spurious  hydrocephalus  is  not  the  same 
in  all  cases.  In  some  there  is  no  appreciable  anatomical  alteration 
in  this  organ.  There  is  no  apparent  difference,  either  in  the 
meninges  or  the  brain  itself,  from  the  condition  which  we  often 
observe  in  those  who  have  died  of  diseases  which  do  not  affect  the 
cerebro-spinal  system.  In  such  cases  the  pathological  state  is 
simply  deficient  innervation,  or  if  there  is  a  structural  change  in 


864  SPURIOUS    HYDROCEPHALUS. 

the   minute   anatomy   of    the   brain,  pathologists   have   not   yet 
discovered  it. 

The  following  case,  which  occurred  in  the  Child's  Hospital  of 
this  city,  is  an  example  of  this  form  of  spurious  hydrocephalus: — 

Case. — A  female  infant,  six  months  old,  died  on  the  24th  day  of 
April,  18G2,  with  the  following  history:  It  was  wet-nursed,  fleshj'-,  and 
apparently  well,  till  six  days  before  death,  w^hen  symptoms  of  gastro- 
intestinal inflammation  were  suddenly  developed.  The  vomiting,  espe- 
cially, was  severe,  continuing  forty-eight  hours.  When  it  ceased,  drow- 
siness supervened,  and  continued  till  the  close  of  life.  The  face  during 
the  four  days  of  stupor  was  pallid  and  cool ;  e^^es  parth'  open,  pupils 
sluggish,  but  of  equal  size;  bowels  rather  torpid,  anterior  fontanelle 
depressed.  When  aroused,  the  infant  noticed  objects  for  a  moment,  and 
immediatel}'' relapsed  into  sleep;  pulse  accelerated  and  not  intermittent, 
the  day  before  death  numbering  one  hundred  and  fifty;  respiration 
accelerated,  without  sighing,  numbering  on  the  same  day  thirt}'.  There 
were  no  convulsions,  and  death  occurred  quietly.  The  brain  weighed 
twenty  and  a  half  ounces,  and  its  appearance  was  perfectly  healthy, 
both  as  regards  consistence  and  vascularity.  The  amount  of  cerebro- 
spinal fluid  in  the  ventricles  and  at  the  base  of  the  brain  was  not  notably 
increased.  The  stomach,  small  and  large  intestines,  were  vascular  in 
streaks  and  patches. 

In  this  case  the  cerebral  symptoms  were  obviously  due  to 
exhaustion  occurring  at  an  early  period,  in  consequence  of  the 
severity  of  the  gastro-intestinal  affection. 

In  a  majority  of  cases,  however,  of  spurious  hydrocephalus, 
according  to  my  observation,  there  is  an  anatomical  alteration  in 
the  state  of  the  brain  and  meninges.  This  consists  in  passive  con- 
gestion of  the  veins,  often  with  transudation  of  serum.  At  the 
same  time  the  cranial  sinuses  are  congested,  and  are  found  at  the 
post-mortem  examination  to  contain  larger  and  more  numerous 
clots  than  are  present  in  those  who  die  of  diseases  which  do  not 
aifect  the  encephalon.  Cases  might  be  cited  as  examples.  The 
cause  of  this  congestion  and  eifusion  is,  in  great  measure,  feeble- 
ness of  the  circulation  due  to  the  general  exhaustion  of  the  patient. 
But  there  is  another  cause.  In  protracted  diseases,  especially  those 
of  a  diarrhceal  character,  there  is  more  or  less  wasting  of  the  brain 
as  well  as  of  other  parts.  This  naturally,  by  way  of  compensation, 
gives  rise  to  congestion  of  the  cerebral  veins  and  to  transudation 
of  serum. 

The  transudation  commonly  occurs  in  this  disease  over  the  superior 
surface  of  the  brain  and  in  the  subarachnoidal  space,  perhaps  also 
more  or  less  in  the  lateral  ventricles.  So  common  is  it  in  the  last 
stage  of  infantile  entero-colitis,  the  summer  epidemic  of  the  cities, 
that  this  stage,  which  is  really  spurious  hydrocephalus,  has  been 


SYMPTOMS.  365 

called  the  stage  of  effusion.  I  shall  relate  ni  another  place 
examples  which  show  the  anatomical  characters  of  this  intestinal 
disease. 

Symptoms. — Spurious  hydrocephalus  most  frequently  results  from 
protracted  diarrheal  comi^laints.  It  may,  however,  result  from 
any  disease  which  is  attended  hy  great  prostration.  As  it  ordi- 
narily occurs,  the  patient  has  for  days  or  weeks  been  gradually 
losing  flesh  and  strength.  Finally  drowsiness  supervenes,  or 
before  the  drowsiness  there  is  sometimes  a  stage  of  irritability. 

Marshall  Hall  describes  two  stages  of  spurious  hydrocephalus. 
In  the  first,  he  says,  "the  infant  becomes  irritable,  restless,  and 
feverish;  the  face  flushed,  the  surface  hot,  and  the  pulse  frequent; 
there  is  an  undue  sensitiveness  of  the  nerves  of  feeling,  and  the 
little  patient  starts  on  being  touched,  or  from  any  sudden  noise; 
there  are  sighing  and  moaning  during  sleep,  and  screaming;  the 
bowels  are  flatulent  and  loose,  and  the  evacuations  are  mucous  and 
disordered."  The  second  stage  he  describes  as  that  of  torpor. 
The  first  stage  often,  however,  does  not  present  those  prominent 
symptoms  which  have  been  described  by  Dr.  Hall,  and  this  stage 
may  even  be  absent,  or  not  appreciable,  especially  in  young 
infants. 

Whether  or  not  commencing  with  the  stage  of  irritability,  the 
disease,  if  not  checked,  gradually  increases.  The  child  soon  be- 
comes drowsy.  He  may  be  aroused  for  a  moment,  but,  unless  con- 
stantly disturbed,  immediately  relapses  into  sleep.  He  is  sometimes 
fretful  when  aroused,  but  in  other  instances  is  quite  indift'erent, 
observing  without  apparent  interest  objects  employed  for  the  pur- 
pose of  amusing  him.  Often  there  are  indications  of  cerebral  pain 
or  distress,  as  contraction  of  the  eyebrows,  etc.,  but  many  of  those 
affected  are  too  young  to  make  known  their  sensations.  Convul- 
sions sometimes  occur  towards  the  close  of  life,  but  they  are  not  so 
common  in  this  disease  as  in  meningitis.  When  they  do  occur, 
they  are  generally  partial  and  often  slight.  The  pulse  is  accelerated 
in  most  patients  prior  to  and  in  the  commencement  of  spurious 
hydrocephalus.  As  the  disease  advances  it  becomes  irregular  and 
intermittent,  and  towards  the  close  of  life  it  is  progressively  more 
.frequent  and  feeble.  The  respiration  at  first  is  not  much  disturbed, 
but  at  length  it  becomes  irregular,  like  the  pulse.  It  is  feeble  and 
accompanied  by  sighs.  Occasionally  there  is  slight  cough.  The 
eyelids  are  partly  open,  the  pupils  no  longer  respond  to  light,  and 
in  advanced  cases  they  have  a  bleared  appearance.  The  diarrhoea, 
which  in  most  instances  precedes  and  causes  the  disease,  continues 


366  SPURIOUS    HYDROCEPHALUS. 

till  the  stage  of  stupor  arrives,  when  the  evacuations  become  less 
frequent  or  cease  altogether.  In  infants  the  stools  are  frequently 
green,  in  older  children  brown  and  sometimes  slimy.  The  febrile 
heat  of  surface,  which  j)receded  the  disease  and  was  present  in'its 
commencement,  disappears ;  the  face  and  hands  become  cool,  the 
features  pallid,  and  the  anterior  fontanelle,  if  open,  is  depressed. 
Death  finally  occurs  in  a  state  of  coma,  or,  if  the  disease  is  recog- 
nized and  proper  remedial  measures  employed,  the  result  may  be 
favorable,  even  when  the  symptoms  are  such  that  if  meningeal 
inflammation  were  the  disease  we  would  consider  the  case  neces- 
sarily fatal. 

The  following  case  is  an  example  of  spurious  meningitis  as  we 
often  meet  it  in  practice: — 

Case. — On  the  13tli  day  of  March,  1859,  I  was  asked  to  see  a  male 
child  t\vent3^-two  months  old,  the  records  of  whose  case  are  as  follows: — 

"Was  well  till  about  three  weeks  ago,  since  which  time  he  has  had 
diarrhffia,  with  febrile  symptoms;  pulse  162,  respiration  52;  has  a  slight 
cough,  with  a  few  mucous  rales;  resonance  on  percussion  of  chest  good; 
is  somewhat  emaciated,  and  appears  languid;  tongue  moist  and  slightly 
furred.  Has  all  the  incisor  and  three  anterior  molar  teeth,  and  the  gum 
is  swollen  over  the  remaining  anterior  molar  and  two  canine  teeth." 

From  the  14th  to  the  18th  there  was  no  material  alteration  in  his 
symptoms,  with  the  exception  that  the  diarrhoea  was  partially  restrained 
by  Dover's  powder  in  one  and  a  half  grain  doses.  On  these  five  days 
the  dejections  numbered  daily  from  one  to  six.  The  pulse  was  uniformly 
frequent,  var3'ing  from  124  to  156,  and  the  respiration  on  two  da^'s,  when 
its  frequency  was  ascertained,  numbered  56  and  46. 

"March  19th,  pulse  124;  has  become  drowsy  since  j-esterday,  and 
when  aroused  is  fretful.  Omit  Dover's  powder.  Treatment,  cold  appli- 
cations to  the  head,  mustard  pediluvia. 

"Evening,  pulse  136;  eyes  constantly  closed  and  head  reclining; 
surface  generally  warm ;  tongue  dr^^  and  furred  ;  vomited  at  first,  but 
has  not  in  three  or  four  days.  Apply  cantharidal  collodion  behind  each 
ear,  and  continue  the  local  treatment. 

"  20th,  pulse  130,  is  constantly  sleeping,  and  when  aroused  is  very 
fretful  and  soon  relapses  into  sleep;  no  unnatural  heat  of  head  and  no 
dejection  since  yesterday.  Treatment,  a  dose  of  castor  oil,  nourishing 
diet. 

"21st,  drowsiness  as  before;  cheeks  sometimes  flushed,  sometimes 
pale  ;  pupils  sensitive  to  light ;  margins  of  eyelids  covered  with  secre- 
tion.    The  bowels  have  been  opened  by  the  oil." 

On  the  22d  and  23d  there  Avas  no  material  change  in  the  symptoms. 
He  was  constantly  sleeping,  except  for  a  moment  when  shaken.  More 
active  stimulation  was  now  employed.  Brandy  was  prescribed,  to  be 
given  every  two  hours  ;  beef-tea  and  milk-porridge  frequently. 

On  the  following  day,  the  24th,  he  was  more  fretful,  and  less  drowsy. 
Brand}-  and  beef-tea  were  continued. 

On  the  25th,  with  the  same  treatment,  there  was  still  further  improve- 
ment ;  drowsiness  nearly  gone  and  lessfretfulness  than  yesterday  ;  rolls 


SYMPTOMS.  367 

tlie  head  occasionally  and  does  not  appear  to  see  distinctl}' ;  has  a  slight 
cough;  bowels  nearly  regular;  i)ulse  100;  respiration  natural;  surface 
warm,  and  no  unnatural  heat  of  head.  The  same  treatment  was  con- 
tinued, and  he  rapidly  and  i'nlly  recovered. 

This  case  is  interesting  on  account  of  the  long  duration  of 
marked  drowsiness,  which  continued  five  clays,  and  yet  tlic  patient 
recovered  fully  in  the  space  of  two  or  three  days  under  the  use  of 
brandy  and  beef-tea. 

In  May,  1860, 1  was  called  to  treat  a  very  similar  case.  A  cliild, 
twenty  months  old,  had  diarrhcca  for  two  weeks,  the  stools  being 
of  a  dark-brown  color,  thin  and  offensive.  He  was  at  first  very 
irritable.  The  pulse  was  constantly  above  130,  and  the  respiration 
was  correspondingly  increased.  The  stage  of  drowsiness  finally 
supervened,  and  for  two  days  he  was  constantly  asleep  unless 
aroused  by  being  shaken.  During  the  somnolent  stage  the  pulse 
numbered  140,  respiration  36.  The  face  and  extremities  were  cool 
and  he  finally  had  a  slight  convulsion.  By  stimulants  and  nutri- 
tious diet  he  began  immediately  to  improve,  and  was  soon  out  of 
danger. 

In  the  folio wino;  case  the  result  was  unfavorable.  This  case  is 
interestino;  on  account  of  the  anatomical  characters  of  the  disease 
as  disclosed  by  the  post-mortem  examination.  It  is  an  example  of 
that  large  class  of  cases  in  which  spurious  hydrocephalus  is  asso- 
ciated with  congestion  of  the  cerebral  vessels  and  serous  eff'usion. 
It  is  exceptional,  however,  as  regards  the  long  duration  of  drowsi- 
ness. Ordinarily,  protracted  cliarrhoeal  maladies  which  end  in  con- 
gestion and  eff'usion,  terminate  fatally  in  two  or  three  days  after 
the  drowsy  period  arrives. 

Case. — "  13th,  1861,  called  to-day  to  a  German  infant  eighteen  months 
old.  It  has  had  diarrhoea  four  weeks  without  regular  and  proper  medi- 
cal attendance;  stools  from  the  first  brown  and  thin;  during  the  last 
eight  or  nine  days  has  been  drowsy  ;  when  aroused,  opens  his  eyes  and 
is  very  fretful,  but  immediately  the  upper  eyelids  gradually  droop,  and, 
unless  disturbed,  he  remains  asleep  with  his  eyes  partially  open  ;  forehead 
warm,  face  cool  and  pallid,  and  limbs  also  rather  cool;  pulse  164,  respi- 
ration 32;  has  had  a  slight  cough  about  one  week,  and  slight  dulness  on 
percussion  over  the  left  infra-scapular  region ;  depression  of  infra-mam- 
mary region  on  inspiration.  Treatment :  Ammon,  carbonat.  gr.  1  every 
two  hours;  nourishing  diet. 

"  Dec.  20th,  has  continued  drowsy  since  the  last  record;  pupils  mode- 
rately dilated  ;  a  thick  secretion  between  eyelids;  right  pupil  consider- 
ably larger  than  the  left ;  vision  apparently  lost  during  the  three  last 
days  ;  pulse  over  140;  respiration  44  per  minute,  accompanied  by  sighing 
since  the  18th;  moans  much  when  awake;  rolls  the  head  frequently; 
during  the  last  six  days  the  surface  back  of  the  ears  has  been  constantly 


308  SPUEIOUS    HYDROCEPHALUS. 

sore  by  vesication  ;  takes  tlie  most  nutritions  diet,  with  bran(l3\  The 
dejections  remain  thin  and  brown,  and  number  three  or  four  daily. 

"  From  this  date  the  diarrhoea  continued,  except  as  it  was  restrained 
by  vegetable  astringents.  The  pulse  continued  frequent,  and  a  slight 
cough  remained.  There  was  on  the  21st  and  22d  partial  abatement  of 
the  drowsiness,  but  on  the  23d  it  was  greater  than  ever.  The  body  was 
somewhat  reduced  at  the  commencement  of  the  cerebral  symptoms,  but 
it  was  now  considerably  emaciated.  The  prostration  increased  daily, 
and  the  hands  were  observed  to  tremble.  The  face  and  hands  became 
more  cold,  while  the  head  was  warm.  On  the  24th  partial  convulsions 
occurred,  followed  by  coma  and  death. 

'^  The  cerebral  veins  and  sinuses  were  generally  congested,  except  in 
the  anterior  portion  of  the  brain,  where  the  appearance  was  normal. 
Between  the  brain  and  its  membranous  covering,  chiefly  at  the  vertex 
and  the  base,  was  an  effusion  of  clear  serum.  The  whole  amount  of 
this  fluid  was  estimated  at  two  ounces.  On  slicing  the  brain,  the 
puncta  were  numerous  and  large,  both  in  the  gray  and  white  portions. 
With  the  exception  of  the  congestion,  the  substance  of  the  brain  pre- 
sented the  normal  appearance.  No  inflammatory  lesions  were  present. 
We  were  not  permitted  to  examine  the  condition  of  the  intestines." 

Diagnosis. — The  only  disease  witli  wliicli  spurious  hydrocephalus 
is  liable  to  be  confounded  is  meningitis.  The  points  of  differential 
diagnosis  are  the  history  of  the  case,  especially  the  antecedent 
diarrhcea  or  other  exhausting  ailment,  evidence  of  prostration 
when  the  cerebral  affection  commenced,  the  depression  of  the  ante- 
rior fontanelle  in  young  children,  and  the  cool  face  and  extremities. 

Prognosis. — If  the  pathological  state  of  the  brain  is  simple  ex- 
haustion, the  disease  can  often  be  arrested  by  judicious  treatment. 
If  an  incorrect  diagnosis  be  made,  and  the  treatment  employed  is 
that  appropriate  for  meningitis,  the  disease  which  it  simulates, 
death  is  almost  inevitable.  If  transudation  of  serum  has  occurred, 
unless  slight,  the  result  is  apt  to  be  unfavorable,  whatever  may  be 
the  treatment.  This  disease  in  childhood  is  more  easily  managed 
than  in  infancy,  but  is  less  frequent.  The  prognosis  is  better  in 
the  cool  months  than  during  the  heat  of  summer.  It  is  more 
favorable  if  the  child  is  over  than  if  under  the  age  of  one  year. 
The  occurrence  of  an  irregular  and  intermittent  j^ulse,  of  respira- 
tion accompanied  by  sighs,  of  inequality  in  the  pupils  or  their 
sluggish  movements,  with  increasing  stupor,  indicates  an  unfavor- 
able issue.  The  cure  of  the  primary  disease,  with  the  pulse  and 
respiration  still  natural,  or  accelerated,  without  change  of  rhythm, 
pupils  sensitive  to  light,  drowsiness  from  which  the  patient  is 
easily  aroused  to  a  state  of  entire  consciousness,  render  recovery 
probable,  with  proper  medication  and  alimentation. 

Treatment. — The  indications  of  treatment  are  twofold:  first, 
to  remove  the  primary  pathological  state  which  is  the  cause  of 


ECLAMPSIA.  369 

the  cerebral  afFection;  and,  secondly,  to  cure  that  affection.  The 
first  is  important,  since  the  successful  treatment  of  a  disease  re- 
quires the  removal  of  the  cause.  The  measures  employed  for  this 
purpose  are  pointed  out  in  our  description  of  the  diarrlujcal  and 
other  maladies  which  produce  spurious  hydrocephalus. 

AVe  may  here  say  that  as  this  disease  is  due  in  a  very  large 
proportion  of  cases  to  the  exhausting  effect  of  long-continued  loose- 
ness of  the  bowels,  astringents  and  alkalies  are  required  in  a 
majority  of  cases  in  the  stage  of  irritability,  and  sometimes  also 
opiates. 

Active  sustaining  measures  are  indicated.  Exhausted  nervous 
power,  as  well  as  passive  cerebral  congestion,  requires  this.  The 
diet  should  be  highly  nutritious,  comprising  such  substances  as 
milk  and  animal  broths,  and  should  be  given  frequently.  Brandy 
is  required  at  short  intervals.  Dr.  Gooch  was  in  the  habit  of 
giving  the  aromatic  spirits  of  ammonia,  properly  diluted,  as  a 
quick  and  active  stimulant.  Six  or  eight  drops  may  be  given  in 
sweetened  water  to  a  child  one  year  old,  and  repeated  every  hour 
in  cases  of  urgency.  If,  by  proper  treatment  of  the  cause,  and  by 
the  use  of  stimulants  and  nutritious  food,  the  patient  does  not 
within  a  few  hours  become  less  stupid  and  more  conscious,  there 
is  that  degree  of  nervous  exhaustion  or  of  serous  transudation  from 
tlie  engorged  cerebral  veins  which  will  render  death  inevitable. 
In  some  cases  it  is  proper  to  produce  moderate  vesication  behind 
the  ears. 


CHAPTER    XI. 

ECLAMPSIA. 


The  term  eclampsia  is  used  in  a  more  restricted  sense  by  some 
writers  than  by  others.  It  is  used  in  the  following  pages  to  desig- 
nate those  convulsive  seizures,  clonic  in  their  character,  sometimes 
general,  sometimes  partial,  which  affect  the  external  muscles. 
Eclampsia  is  therefore  synonymous  with  clonic  convulsions.  It 
consists  in  a  rapid,  forcible,  and  involuntary  muscular  contraction, 
alternating  with  relaxation.  It  is  distinguished  from  chorea  in 
the  fact  that  the  latter  is  a  more  permanent  state,  and  is  charac- 
terized by  muscular  movements  which  are  partially  under  the 
control  of  the  will,  and  are  not  so  violent. 
24 


370  ECLAMPSIA. 

Eclampsia  occurs  in  a  great  variety  of  diseases,  some  of  which 
are  located  in  the  cerebro-spinal  system,  some  in  other  parts  of  the 
body,  and  some  are  constitutional.  It  may  also  be  produced  by 
temporary  derangements  of  system,  not  sufficiently  severe  to  be 
considered  disease,  and  by  powerful  mental  impressions,  those  of 
an  emotional  nature  affecting  the  delicate  and  sensitive  nervous 
system  of  the  child.  Pathologists  recognize  three  distinct  forms 
of  eclampsia.  The  term  essential  or  idiopathic  is  used  when  the 
convulsions  have  no  appreciable  anatomical  character,  that  is,  when 
there  is  no  apparent  pathological  state  in  the  brain  or  elsewhere 
which  gives  rise  to  the  attack.  For  example,  if  a  child  dies  in 
convulsions  from  fright,  and  all  the  organs,  including  the  brain,  are 
found  in  their  normal  state,  the  eclampsia  is  called  idiopathic  or 
essential.  If  the  cause  is  disease  of  the  brain  or  spinal  cord,  it  is 
termed  symptomatic.  If  it  arises  from  disease  elsewhere,  as  from 
pneumonia,  the  term  sympathetic  is  employed.  This  is  in  the 
main  a  good  division,  but  eclampsia  may  be  at  the  same  time 
sympathetic  and  symptomatic,  as  when  it  occurs  in  consequence 
of  congestion  of  brain,  which  is  induced  by  severe  and  frequent 
paroxysms  of  hooping-cough. 

Causes. — Eclampsia  occurs  at  any  period  of  infancy  and  child- 
hood, but  it  is  much  more  rare  after  the  period  of  six  or  seven  years 
than  previously.  Some  children  are  more  liable  to  it  than  others. 
It  is  produced  in  one  by  an  agency  which  in  another  has  no  ap- 
preciable eifect.  There  are  some,  generally  those  of  an  impressible 
nervous  system,  who  are  seized  with  convulsions  whenever  there  is 
any  slight  derangement  in  the  digestive  or  other  organs.  Eclampsia 
is  frequent  in  certain  families.  Thus,  Bouchut  mentions  a  family  of 
ten  persons,  all  of  whom  had  convulsions  in  their  infancy.  One 
of  them  married,  and  had  ten  children,  all  which,  with  one  excep- 
tion, had  convulsions. 

The  exciting  causes  of  eclampsia  are  too  numerous  to  be  men- 
tioned in  full.  It  is  a  symptom  in  nearly  all  cerebral  diseases.  It 
is  produced  in  the  nursling  by  changes  in  the  milk  with  which  it  is 
nourished.  These  changes  are  usually  due  to  violent  emotions  of 
the  mother,  as  anger,  fright,  and  grief,  to  the  use  of  acescent  or 
indigestible  food,  or  to  derangement,  temporary  or  permanent,  in 
her  health.  Thus,  in  a  case  related  to  me,  the  catamenia  so 
afl'ected  the  milk  that  the  child  was  seized  with  eclampsia  at  each 
monthly  period.  In  childhood  the  most  common  cause  of  clonic 
convulsions  is  the  presence  of  some  irritant  in  the  primes  vise.  All 
kinds  of  fruit,  even  the  mildest,  may  produce  the  disease,  especially 


PREMONITORY    STAGE.  371 

when  eaten  unripe  or  taken  in  undue  quantity.  I  have  known  an 
infant  to  he  seized  wltli  convulsions  from  eating  strawherries, 
which  parents  usually  regard  as  harmless,  and  one  of  the  most 
violent  and  protracted  cases  of  eclampsia  which  I  have  witnessed, 
occurred  in  a  child  over  the  age  of  six  years,  from  swallowing,  in 
considerahle  quantity,  the  parenchymatous  portion  of  an  orange. 
Constipation,  worms,  dysentery,  intussusception,  and  painful  denti- 
tion are  also  causes  which  are  located  in  the  digestive  apparatus. 
Inilannnation  in  some  part  of  the  respiratory  apparatus  is  a  not 
infrequent  cause.  Thus  eclampsia  occurs  occasionally  in  severe 
coryza,  in  consequence,  according  to  some,  of  the  proximity  of  the 
inflamed  surface  to  the  brain,  and  the  consequent  afflux  of  blood 
to  this  organ.  It  is  a  common  complication  also  of  pertussis  and 
pneumonia.  It  occurs  often  at  the  commencement  of  two  of  the 
eruptive  fevers,  namely,  smallpox  and  scarlet  fever,  and  in  the 
course  of  the  latter  disease. 

Violent  emotions  of  the  child  may  also  cause  eclampsia.  Bouchut 
relates  the  case  of  a  girl,  five  years  old,  who  was  corrected  before 
her  companions,  and  was  so  aftected  by  anger  that  convulsions 
occurred.  Residence  in  close  and  overheated  apartments,  or  in 
streets  where  the  air  is  loaded  with  offensive  vapors  and  is  stifling, 
is  a  predisposing  cause,  so  that  there  is  a  larger  proportion  of  deaths 
from  convulsions  in  the  cities  than  in  the  country. 

In  young  children,  burns,  even  when  not  very  severe,  are  apt  to 
terminate  suddenly  in  eclampsia,  succeeded  by  coma  and  death. 
Urinary  calculi,  both  renal  and  vesical,  frequently  produce  the 
same  result. 

Such  are  the  more  common  causes  of  eclampsia.  It  is  seen  that 
they  are  of  two  kinds,  predisposing  and  exciting.  An  excitable 
or  impressible  state  of  the  nervous  system  constitutes  the  chief 
predisposition  to  the  disease.  Plethora,  or  its  opposite  state, 
angemia,  increases  the  liability  to  an  attack. 

Premonitory  Stage. — In  the  majority  of  cases  there  are  pro- 
dromic  symptoms,  which  the  experienced  and  careful  physician 
can  detect,  so  as  to  forewarn  friends.  The  child  is  perhaps  more 
or  less  drowsy,  and,  when  disturbed,  fretful.  The  eyes  often  have 
a  wild  or  unnatural  appearance ;  occasionally  they  are  fixed  for  a 
moment  on  an  object,  and  yet  apparently  without  noticing  it.  The 
sleep  is  disturbed ;  in  some  there  is  unusual  heat  of  head,  and,  if 
old  enough,  complaint  of  headache.  At  times,  especially  if  the 
primary  disease  is  febrile  or  inflammatory,  there  is  incoherence  of 
thought  or  expression,  or  even  actual  delirium.     In  some  children, 


372  ECLAMPSIA. 

when  eclampsia  is  tlireatening,  the  thumbs  are  seen  to  be  carried 
often  across  the  palms.  I  have  observed  this  especially  during 
the  convulsive  cough  of  pertussis.  A  very  important  prognostic 
symptom  is  a  sudden  starting,  or  twitching  of  the  limbs.  This 
shows  that  the  nervous  system  is  profoundly  impressed,  and  but 
slight  additional  excitation  is  required  to  develop  eclampsia.  This 
sudden  starting  not  infrequently  precedes  the  attack  several  hours, 
and  gives  sufficient  forewarning. 

The  prodromic  symptoms  are  often  disregarded  by  friends  who 
do  not  understand  their  significance.  Even  physicians,  in  the  haste 
of  their  visits,  in  many  instances  do  not  notice  them.  The  symp- 
toms which  precede  symptomatic  and  sympathetic  eclampsia  are, 
moreover,  blended  with  those  of  the  primary  aftection,  and  hence 
another  reason  why  they  are  apt  to  be  overlooked.  When  the 
convulsions  are  about  to  commence,  the  child  generally  lies  quiet ; 
the  eyes  are  open  and  fixed.  If  spoken  to  or  shaken,  he  takes  no 
notice,  and  does  not  speak.  The  direction  of  the  eyes  is  then 
changed;  often  they  are  turned  up;  sometimes  there  is  strabismus. 
The  face  may  be  pale  or  flushed,  and  often,  especially  in  cerebral 
diseases,  the  features  present  patches  or  streaks  of  a  flushed  appear- 
ance, while  around  them  the  natural  color  is  preserved.  Immedi- 
ately before  the  spasmodic  movements  the  child  occasionally  utters 
a  piercing  scream,  which  is  probably  involuntary,  though  it  seems 
like  a  supplication  for  help.  The  duration  of  the  prodromic  stage 
is  very  difierent  in  dififerent  cases.  It  may  last  from  a  few  minutes 
to  several  hours,  or  even  more  than  a  day. 

Symptoms. — Eclampsia  is  general  or  partial,  li  general^  the  mus- 
cles of  the  face,  eyes,  eyelids,  and  of  all  the  limbs,  are  in  a  state  of 
rapid  involuntary  contraction,  alternating  with  relaxation.  The 
features  lose  their  natural  expression,  and  are  distorted ;  the  mouth 
is  drawn  out  of  shape,  often  to  one  side,  by  the  violent  muscular 
action ;  the  teeth  are  pressed  together  by  tonic  contraction  of  the 
masseters,  and  may  be  violently  struck  together,  so  as  to  lacerate 
the  tongue,  if  it  protrude,  or  are  ground  upon  each  other.  Unless 
the  attack  is  of  short  duration,  frothy  saliva,  perhaps  tinged  with 
blood  from  the  injured  tongue,  collects  between  the  lips.  The  eye- 
lids are  usually  open,  and  in  severe  cases  the  eyes  are  turned  so 
that  the  pupils  are  lost  under  the  upper  eyelids,  or  the  muscles  of 
the  eyes  are  involved  in  the  spasmodic  movements,  so  that  the  eye- 
balls are  forcibly  drawn  from  side  to  side.  Occasionally,  strabismus 
occurs.  "While  the  features  are  thus  distorted,  the  head  is  forcibly 
retracted,  or  is  turned  to  one  side;  the  forearms  are  alternately 


SYMPTOMS,  373 

pronatcd  and  supinated ;  the  thumbs  and  fingers  are  convulsively 
flexed,  so  that  the  thumbs  lie  across  the  palms,  and  are  covered  by 
the  fingers  ;  the  great  toe  is  adducted,  the  other  toes  flexed;  and 
the  toes,  as  well  as  legs,  participate  more  or  less  in  the  spasmodic 
movements. 

In  general  convulsions,  consciousness  is  usually  lost.  The  head 
is  hot  previously  to  and  during  the  attack — at  least  in  the  first 
part  of  it — and  the  face  flushed.  In  exceptional  cases,  especially 
in  sympathetic  eclampsia,  the  head  is  cool  and  the  face  pale.  The 
pulse  is  somewhat  accelerated,  as  well  as  the  respiration,  and  the 
latter  is  rendered  irregular  if  the  respiratory  muscles,  especially 
those  of  the  larynx,  are  involved,  as  they  generally  arc.  The 
sphincters  arc  relaxed  during  the  convulsive  attack,  so  that  in 
many  cases  the  urine  and  stools  are  passed  involuntarily. 

Partial  eclampsia  is  more  common  than  the  general  form ;  it 
occurs  in  the  muscles  of  the  face,  including  those  of  the  eye,  of  the 
face,  and  of  one  or  both  upper  extremities,  or  of  the  face  and  the 
extremities  on  one  side.  The  spasmodic  movements  may  be  even 
limited  to  the  muscles  of  the  eyes,  and  they  often  occur  only  in 
these  muscles  and  those  of  the  face.  Rarely,  if  ever,  does  eclampsia 
affect  the  legs  without  affecting  also  the  muscles  of  the  arms  and 
face.  In  partial  convulsive  attacks,  sensation  and  consciousness 
are  in  some  not  entirely  lost,  but  in  others  they  are  not  manifested 
if  present. 

The  duration  of  an  attack  of  eclampsia  varies  in  different  cases 
from  a  few  minutes  to  several  hours.  The  average  is  not  more 
than  from  five  to  fifteen  minutes.  It  does  not  often  continue 
longer  than  three  or  four  hours  in  the  severest  cases.  It  is  some- 
times  said  to  last  a  much  longer  time,  even  for  days,  but  there  are 
in  these  cases  intermissions.     Violent  attacks  are  usually  short. 

"When  the  convulsion  ends  favorably,  the  spasmodic  movements 
become  less  and  less  strong,  and  finally  cease.  The  child  then 
takes  a  deep  inspiration,  after  which  it  lies  quiet,  and  the  respi- 
ration remains  regular  or  moderately  accelerated.  Some  fully  re- 
cover in  a  few  minutes  if  the  eclampsia  has  been  light  and  the 
cause  transient,  and  seem  to  experience  no  inconvenience  except 
soreness  of  the  muscles  and  fatigue.  Others  soon  recover  conscious- 
ness, and  their  temperature,  respiration,  and  circulation  become 
natural,  but  they  remain  dull  for  a  time,  their  minds  are  bewil- 
dered, and  they  are  perhaps  unable  to  speak.  In  a  few  hours 
these  untoward  symptoms  pass  away.  In  essential,  and  in  a  large 
proportion  of  cases  of  sympathetic  eclampsia,  if  properly  treated, 


374  ECLAMPSIA. 

and  if  the  cause  is  recognized  and  removed,  there  is  no  recurrence 
of  the  convulsion ;  with  others  it  is  different.  In  many  cases,  es- 
peciall}''  of  symptomatic  eclampsia  and  of  sympathetic,  in  which  the 
cause  is  grave  and  persistent,  the  convulsions  return  after  a  varia- 
ble period  of  a  few  minutes  or  a  few  hours.  Six  or  eight  or  more 
convulsions  may  occur  within  twenty-four  hours.  Rarely  they 
occur  several  times  daily  for  several  consecutive  days,  but  severe 
convulsions,  repeated  at  short  intervals  for  twenty-four  or  forty- 
eight  hours,  usually  end  in  fatal  congestion  of  the  brain  or  serous 
effusion.  I  once  attended  an  infant  about  six  months  old,  who  had 
from  four  to  twelve  convulsions  daily  for  eleven  days,  caused  prob- 
ably by  a  vesical  calculus,  as  there  was  dysuria,  and,  at  times, 
bloody  urine.  Some  days  after  the  convulsions  were  controlled, 
while  we  were  deferring  exploration  of  the  bladder,  death  occurred 
suddenly,  and  the  autopsy  was  not  permitted.  This  case  will  be 
detailed  elsewhere.  Bouchut  has  witnessed  a  case  of  hooping- 
cough  in  which  there  were  daily  convulsions  for  eighteen  days. 

In  severe  eclampsia,  the  respiration  is  so  embarrassed  and  cir- 
culation so  retarded  that  congestion  of  various  organs  results. 
This  passive  congestion  in  the  respiratory  organs  is  indicated  by 
moist  rales  in  the  larynx  and  bronchial  tubes ;  occurring  in  the 
brain,  it  is  indicated  by  profound  stupor.  It  has  already  been 
stated  that  death  may  occur  from  the  cerebral  congestion,  which, 
continuing,  is  apt  to  end  in  effusion  of  serum  or  extravasation  of 
blood.  In  these  cases  the  convulsive  movements  cease,  but  there 
is  no  return  of  consciousness.  The  child  lies  quiet,  as  if  in  sleep, 
with  pupils  not  readily  acted  upon  by  light,  and  often  somewhat 
dilated ;  gradually  the  limbs  grow  cool  and  the  pulse  feeble,  and 
fatal  coma  supervenes. 

Death  does  not  ordinarily  occur  from  one  attack.  There  are 
several  at  intervals,  during  which  the  stupor  is  gradually  becoming 
more  and  more  profound,  till,  finally,  there  is  total  loss  of  con- 
sciousness and  sensation.  This  is  the  most  frequent  mode  of  death, 
namely,  death  from  coma.  Apnoea  may  occur  in  the  first  attack, 
ending  life  abruptly  and  unexpectedly,  but  in  other  instances  it 
does  not  result  till  after  several  seizures,  when,  at  length,  one  more 
violent  than  the  others  interrupts  the  respiratory  function  and 
causes  death. 

Occasionally,  when  life  is  preserved,  there  is  some  permanent  ill 
effect  of  eclampsia.  Bouchut  says :  "  The  origin  of  certain  perma- 
nent contractions  which  bring  on  deviation  of  the  head  or  of  other 
parts,  retraction  of  the  limbs,  paralysis,  etc.,  must  be  referred   to 


ANATOMICAL    CHARACTERS.  375 

the  convnlsions  of  the  muscles.  I  have  seen  several  children  in 
whom  torticollis  had  no  other  cause.  The  drooping  of  the  upper 
eyelid,  stral)ismus,  irregularity  of  the  mouth,  severe  contractions 
of  the  limbs,  often  depend  on  this  influence.  These  accidents  are 
consequences  of  essential  as  well  as  of  symptomatic  convulsions." 

Anatomical  Characters. — The  morbid  anatomy  pertaining  to 
eclampsia  is  in  most  cases  twofold :  first,  the  pathological  states 
which  precede  and  cause  the  convulsive  movements ;  secondly, 
those  which  result  from  them.  We  have  seen  that  in  sympathetic 
eclampsia  the  diseases  which  sustain  a  causative  relation  are  very 
numerous ;  some  are  constitutional,  others  local,  and  the  latter  may 
have  their  seat  in  almost  any  part  of  the  economy,  distinct  from 
the  cerebro-spinal  axis.  In  some  cases  of  sympathetic  eclampsia 
the  immediate  cause  is  too  active  a  circulation,  a  state  of  hypersemia 
of  the  cerebral  vessels. 

It  has  already  been  stated  that  this  hj-perremia  may  be  diagnosti- 
cated in  young  infants  in  whom  the  anterior  fontanelle  is  open.  Such 
infants,  seized  with  acute  inflammation  of  the  mucous  surfaces  or 
of  the  lungs,  often  present  a  full  and  rapid  pulse  and  a  convex  and 
forcibly  pulsating  fontanelle  before  the  eclampsia  begins.  In  other 
cases  of  sympathetic  eclampsia  the  primary  disease  induces  passive 
congestion  of  the  brain,  and  this  in  turn  gives  rise  to  convulsions. 
Eclampsia  occurring  during  the  paroxysms  of  hooping-cough 
aflfords  an  example.  In  the  contagious  diseases,  as  smallpox  and 
scarlet  fever,  eclampsia  is  doubtless  often  produced  by  the  direct 
action  of  the;  specific  virus  on  the  cerebro-spinal  system.  There- 
fore, in  a  considerable  proportion  of  cases  of  eclampsia  due  to 
diseases  not  located  in  the  cerebro-spinal  system — in  other  words,  of 
sympathetic  eclampsia— the  primary  disease  induces  a  pathological 
state  of  the  cerebral  vessels  or  of  the  blood  which  circulates 
through  them,  which  state  immediately  precedes  and  accompanies 
the  convulsions. 

In  other  cases  of  s^mipathetic  eclampsia  the  convulsive  move- 
ments are  produced  by  the  primary  disease,  acting  directly  on  the 
nervous  system,  through  the  medium  of  the  nerves,  without  caus- 
ing any  appreciable  alteration  in  the  state  of  the  cerebro-spinal  axis. 
Thus  Barrier  relates  three  fatal  cases  of  convulsions  occurring  in 
pneumonia,  in  none  of  which  was  there  anj- thing  abnormal  in  the 
condition  of  the  brain  or  its  membranes. 

The  pathological  state  preceding  symptomatic  eclampsia  difiJers 
in  different  cases,  since  convulsions  occur  in  almost  every  disease 
of  the  brain  and  its  membranes.     The  immediate  cause  of  this  form 


376  ECLAMPSIA. 

of  eclampsia  may  be  active  or  passive  cerebral  congestion,  with  or 
without  effusion  ;  it  may  be  compression  of  the  brain  from  various 
causes ;  it  may  be  a  deficiency  as  well  as  excess  of  the  cerebro- 
spinal fluid. 

In  essential  eclampsia  the  cause  sometimes  produces  congestion 
of  the  brain  prior  to  the  convulsive  seizure.  In  other  cases,  as 
when  convulsions  occur  immediately  from  the  effect  of  anger  or 
fright,  there-  is  no  appreciable  change  in  the  state  of  the  nervous 
centres  previously  to  the  attack. 

Again,  eclampsia,  especially  when  severe  and  protracted,  and 
when  occurring  in  successive  attacks,  may  be  the  cause  of  certain 
lesions.  It  produces  congestion  of  the  brain  and  membranes,  and 
perhaps  of  the  spinal  cord.  Sometimes,  if  the  congestion  is  great, 
there  is  also  escape  of  serum  from  the  distended  capillaries,  and 
the  fibrin  in  the  larger  vessels,  as  the  sinuses,  may  coagulate. 

The  congestion  resulting  from  eclampsia  may  give  rise  to  extra- 
vasation of  blood  and  the  formation  of  a  clot.  If  this  accident 
occur,  there  is  often  paralysis  affecting  more  or  less  of  one  side, 
permanent  or  gradually  disappearing. 

It  may  be  difiicult  to  decide  whether  the  cerebral  congestion 
precedes  the  eclampsia  or  is  its  result ;  but  in  those  cases  in  which 
it  precedes  and  operates  as  a  cause,  it  is  no  doubt  increased  dui-ing 
the  convulsive  period.  The  spasmodic  muscular  action,  b}'  render- 
ing respiration  irregular  and  imperfect,  also  leads  to  congestion  of 
the  lungs  and  sometimes  of  the  abdominal  organs. 

Diagnosis. — The  only  disease  for  which  there  is  danger  of  mis- 
taking eclampsia  is  epilepsy.  M.  Ozanam  mentions  the  following 
means  of  distinguishing  the  two:  "Eclampsia  difiers  from  epilepsy 
in  the  frequent  occurrence  of  prodromic  symptoms ;  the  clonic 
form  of  the  convulsions,  the  rare  appearance  of  froth  in  the  mouth, 
the  absence  of  a  hideous  livid  aspect  of  the  countenance,  the  spas- 
modic and  sobbing  character  of  the  respiration,  frequency  of  the 
pulse,  and  a  state  of  quiet  without  snoring  which  succeeds  an 
attack."  In  the  young  child,  however,  the  above  points  of  dis- 
tinction are  not  reliable  as  a  means  of  differential  diagnosis. 
Some  patients,  who  seem  to  have  genuine  attacks  of  eclampsia  in 
infancy  and  childhood,  prove  to  be  epileptic  in  subsequent  years. 
The  usual  period  of  eclampsia  is  prior  to  the  age  of  eight  years, 
and  if  convulsions  occur  after  this  age  without  apparent  exciting 
cause,  or  from  trifling  causes,  the  disease  is  probably  epilepsy ;  if 
prior  to  the  age  of  eight  years,  and  especially  of  three  or  four,  they 
are  in  the  vast  majority  of  cases  the  convulsions  of  eclampsia. 


PROGNOSIS.  377 

It  is  often  difficult  to  ascertain  the  form  of  eclampsia,  whether 
essential,  symptomatic,  or  sympathetic — in  other  words,  to  deter- 
mine the  cause — till  after  the  convulsions  cease.  This  is  especially 
true  when,  as  is  frequently  the  case,  the  physician  is  not  sum- 
moned till  the  convulsive  movements  hegin,  and  it  is  necessary 
that  he  should  act  promptly,  with  but  little  knowledge  of  the 
child's  previous  history.  If  there  is  an  obvious  antecedent  disease, 
as  hooping-cough  or  meningitis,  the  cause  is  apparent ;  but  if  the 
previous  health  has  been  good,  or  but  slightly  disturbed,  it  may 
be  necessary  to  make  more  than  one  visit  or  examination  in  order 
to  ascertain  the  scat  and  character  of  the  cause.  In  the  majority 
of  cases  of  convulsions  occurring  suddenly  in  a  state  of  previous 
good  health,  the  cause  is  seated  in  the  intestines,  but  sudden  and 
unexpected  attacks  may  be  due  to  the  commencement  of  some 
inflammatory  affection,  as  pneumonia,  or  of  a  febrile  disease,  as 
smallpox.  Unless  the  eclampsia  is  speedily  fatal,  the  physician, 
if  he  examine  carefully,  will,  in  most  cases,  soon  be  able  to  ascer- 
tain the  nature  of  the  cause,  and  diagnosticate  the  form  of  the 
disease. 

Peognosis. — Symptomatic  eclampsia  is  always  serious.  If  con- 
vulsions occur  in  the  course  of  a  cerebral  disease,  it  indicates  the 
approach  of  death,  but  if  at  the  commencement,  some  recover. 
The  recurrence  of  it,  whatever  the  cerebral  disease,  is  an  almost 
certain  prognostic  of  death. 

In  idiopathic  or  essential  convulsions  the  prognosis  depends  on 
the  severity  of  the  attack,  and  on  the  age,  strength,  and  previous 
condition  of  the  child.  If  there  are  predisposing  or  co-operating 
causes,  as  a  nervous  or  excitable  temperament,  or  dentition,  the 
prognosis  is  less  favorable  than  when  such  causes  are  absent. 

In  sympathetic  eclampsia  the  prognosis  varies  greatly,  according 
to  the  nature  of  the  primary  disease,  and  often  according  to  the 
stao-e  of  that  disease.  If  convulsions  occur  at  the  commencement 
of  an  eruptive  fever,  they  generally  subside  without  untoward 
symptoms,  and  the  fever  pursues  a  favorable  course.  Eclampsia, 
after  the  appearance  of  the  eruption,  is  premonitory  of  a  fatal 
result.  I  have  not  yet  known  a  patient  with  scarlet  fever  recover 
who  had  convulsions  after  the  rash  had  covered  the  body,  and  ex- 
perienced physicians  of  this  city  tell  me  that  their  observations 
correspond  with  mine.  Dr.  J.  F.  Meigs,  however,  relates  one 
favorable  case.  If  the  cause  of  the  eclampsia  is  located  in  or  upon 
the  mucous  surfaces,  a  majority  recover  with  judicious  treatment. 


378  ECLAMPSIA. 

In  convulsions  consequent  on  pneumonia  or  a  burn,  more  die  than 

recover. 

The  prognosis  in  eclampsia  is  more  favorable  if  the  parallelism 
of  the  eyes  is  retained,  the  pupils  remain  sensitive  to  light,  and 
consciousness  soon  returns.  A  fatal  termination  may  be  predicted, 
if,  after  the  convulsion,  the  child  remains  stupid,  without  any 
evidence  of  returning  consciousness. 

Treatjient, — Fortunately,  inasmuch  as  the  physician  is  often 
required  to  treat  eclampsia  in  ignorance  of  the  cause,  the  same 
measures  are  demanded,  to  a  considerable  extent,  in  all  cases, 
whether  the  form  be  essential,  symptomatic,  or  sympathetic.  As 
early  as  possible  in  the  attack  the  feet  should  be  placed  in  hot 
water  to  which  mustard  is  added,  or,  if  it  can  be  procured  with 
little  delay,  a  general  warm  bath  may  be  used  in  place.  This 
has  a  soothing  effect  upon  the  nervous  system  and  promotes 
muscular  relaxation,  while  it  also  produces  derivation  of  blood 
from  the  cerebro-spinal  axis.  It  is,  therefore,  useful,  especially 
in  those  cases  in  which  active  or  passive  congestion  precedes  the 
eclampsia;  it  is  also  useful  as  a  preventive  of  passive  congestion 
and  consequent  oedema  of  the  brain,  lungs,  and  other  organs,  which 
are  the  most  serious  results  of  eclampsia.  It  should  be  continued 
from  six  to  fifteen  or  twenty  minutes,  according  to  the  severity 
and  duration  of  the  attack ;  at  the  same  time  cold  applications 
should  be  made  to  the  head,  until  its  temperature,  which  is 
usually  increased,  is  reduced.  The  application  of  a  cloth,  fre- 
quently wu'ung  out  of  cold  water,  is  the  most  convenient  and 
ready  mode  of  employing  this  agent.  Cold  thus  employed  acts 
promptly  in  contracting  the  vessels  of  the  brain  and  meninges, 
and  diminishing  the  cerebral  congestion.  It  tends,  therefore,  to 
remove  one  of  the  chief  dans-ers. 

As  a  large  proportion  of  convulsive  attacks  originate  in  the  con- 
dition of  the  bowels,  either  solely  or  in  part,  it  is  advisable,  unless 
there  is  a  previous  diarrhoial  affection,  to  prescribe  an  aperient. 

The  common  enema  of  soap  and  water  will  usually  produce  a 
free  and  speedy  evacuation,  and  will  sometimes  disclose  the  cause 
of  the  eclampsia  in  the  expulsion  of  seeds,  or  other  indigestible 
substances  or  scybala.  A  cathartic  is  also  often  required,  especially 
if  the  enema  fail  to  produce  suilicient  evacuations.  In  those  that 
are  robust,  and  especially  in  those  beyond  the  age  of  two  or  three 
years,  calomel  is  an  excellent  purgative,  is  easily  given,  and  is 
prompt  in  its  action.  If  the  symptoms  indicate  intestinal  inflam- 
mation, the  milder  purgatives,  as  castor  oil,  are  preferable,  as  they 


TREATMENT.  379 

also  are  in  young  or  feeble  children.  Tf  the  recent  ingesta  of  the 
patient  consisted  of  fruit  or  of  sul)stances  of  an  indigestible 
character,  an  emetic  is  appropriate;  a  teaspoonful  of  the  syrnp  of 
ipecacuanha,  repeated  if  necessary  in  fifteen  or  twenty  minutes, 
may  be  given  to  a  young  (fluid,  or  this  syrup  in  combination  with 
hive  syrup  to  one  older  and  more  robust.  Aside  from  the  ejection 
of  the  offending  substance  which  it  produces,  an  emetic  has  some 
effect  in  controlling  the  convulsive  movements. 

Convulsions  sometimes  cease,  apparently,  in  consequence  of  the 
muscular  relaxation  caused  by  the  emetic.  By  such  measures, 
or  even  without  them,  the  attack  usually  terminates  in  a  short 
time ;  but  if  it  continue,  and  there  is  considerable  heat  of  head  or 
other  indication  of  active  congestion  of  this  organ,  we  may  try 
compression  of  the  carotids  by  the  fingers,  as  recommended  by 
Trousseau.  This  distino-uished  observer  believed  that  he  succeeded 
in  diminishing  the  afflux  of  blood  to  the  brain,  and  thereby 
shortening  eclampsia,  by  this  simple  expedient.  Brown-Sequard 
(Remarks  before  the  United  States  Medical  Association,  1866)  has 
stated  that  this  result  is  due,  not  so  much  to  compression  of  the 
carotid,  as  to  pressure  on  the  cervical  portion  of  the  sympathetic 
nerve,  which  (pressure)  causes  contraction  of  the  cerebral  vessels. 

If  the  convulsions  do  not  cease  by  the  employment  of  the 
measures  recommended  above,  one  or  two  leeches  may  be  applied 
to  the  temples  if  the  child  is  robust,  and  there  is  increased  heat  of 
face  or  head.  The  abstraction  of  blood  directly  from  the  head 
has  the  obvious  effect  of  diminishing  cerebral  congestion,  and 
has  been  the  means  of  shortening  the  attack  and  saving  life. 
Antispasmodics  have  been  used  for  a  long  period  in  cases  of 
eclampsia,  and  they  are  recommended  in  our  standard  works.  I 
have  never  observed  any  benefit  from  the  use  in  clonic  convulsions 
of  either  assafoetida  or  valerian  ;  though  I  have  occasionally  ordered 
the  use  of  such  agents  both  by  the  mouth  and  by  enema.  Chloro- 
form, whether  inhaled  or  swallowed,  does  control  the  convulsive 
movements.  In  protracted  or  frequently  recurring  eclampsia, 
especially  when  it  is  due  to  a  highly  sensitive  nervous  tempera- 
ment, and  there  is  probabl}^  little  or  no  cerebral  congestion,  this 
is  one  of  the  most  reliable  agents  employed  by  inhalation,  and  it 
is  not  unsafe  if  cautiousl}^  used  by  the  physician  himself.  It 
should  be  employed  only  in  the  convulsion,  and  withheld  the 
moment  the  spasmodic  movements  cease.  In  symptomatic  eclamp- 
sia, or  in  the  other  forms,  if  there  are  indications  of  cerebral 
congestion,  I  would  not  recommend  its  use.     Dr.  A.  P.  Merrill 


380  ECLAMPSIA. 

{Amer.  Journ.  of  3Icd.  Sei.,  Oct.  1865)  gives  chloroform  hj  the 
mouth  in  the  treatment  of  this  disease,  and  in  doses  which  most 
practitioners  would  hesitate  to  prescribe.  He  has  given  even  a 
teaspoonful  at  a  dose,  to  a  child  a  few  years  old,  with  satisfactory 
result.  In  most  of  those  cases,  however,  in  which  chloroform  is 
useful,  the  hydrate  of  chloral  promises  to  be  a  safer  and  efficient 
substitute,  and  it  is  more  easily  administered.  I  have  already 
S]3okcn  of  the  employment  of  chloral  in  the  convulsions  of  menin- 
gitis. 

The  propriety  of  prescribing  opium  in  any  form  of  convulsive 
attacks  in  children  is  doubted  by  many  on  account  of  the  drowsi- 
ness which  it  produces.  There  can  be  no  doubt,  however,  of  the 
propriety  and  the  good  effect  of  its  use  in  certain  cases  of  essential 
and  of  sympathetic  eclampsia.  I  refer  to  those  cases  in  which 
attacks  of  eclampsia  occur  with  intervals  during  which  there  is  no 
stupor,  and  the  patient  preserves  consciousness.  Opiates  may  occa- 
sionally be  of  service  in  other  cases,  but  in  such  they  are  especially 
indicated.  Thus,  recentl}^,  in  my  practice,  an  infant  six  weeks  old, 
in  whom  there  was  an  hereditary  predisposition  to  eclampsia,  was 
taken  with  diarrhcea,  and  soon  after  with  convulsions.  The  attack 
was  short,  but  after  a  brief  interval  it  returned,  and  during  the 
subsequent  twelve  hours  there  were  about  twenty  convulsions. 
There  was  no  unusual  heat  of  head  or  prominence  of  the  anterior 
fontanelle,  or  other  evidence  of  cerebral  congestion.  The  green  and 
unhealthy  appearance  of  the  stools  showed  that  the  cause  was 
located  in  the  intestines.  After  trial  of  various  remedies,  among 
which  were  antispasmodics,  these  convulsive  seizures  were  soon 
relieved  by  the  use  of  paregoric  in  doses  of  five  drops,  which  also 
had  a  salutary  eftect  on  the  cause  of  the  eclampsia,  and  in  a  few 
days  there  was  complete  restoration  to  health. 

In  recent  times  the  attention  of  the  profession  has  been  directed 
to  the  bromide  of  potassium  as  a  remedy  in  convulsive  disorders. 
It  is  ordinarily  prescribed  alone,  in  powder  or  solution.  I  can 
speak  favorably  of  its  use  in  obstinate  cases,  not  only  in  children 
approaching  the  age  of  puberty,  but  in  infants,  especially  when  the 
cause  is  obscure  or  beyond  our  reach.  It  produces  a  decided  impres- 
sion on  the  nervous  system,  so  as  to  diminish  the  liability  to  spas- 
modic aftectious.  In  the  following  interesting  case,  already  alluded 
to,  this  agent  was  employed  with  the  effect  of  relieving  entirely  the 
convulsive  seizures,  although  the  cause  continued.  On  the  29th  of 
January,  1866,  I  was  asked  to  see  an  infant  six  months  old,  who, 
during  the  preceding  week,  had  had  an  average  of  eight  convulsions 


TREATMENT.  381 

dail}^;  eacli  convulsion  lasted  about  eight  or  ten  minutes,  and  was 
general ;  tlie  child  was  nursing,  and  had  no  teeth,  and  no  decided 
swellini!"  of  the  gums.  A  careful  examination  could  detect  no 
cause,  though  the  infant  was  fretful  and  seemingly  in  considerable 
pain.  Some  days  subsequently  it  was  observed  to  pass,  with  appa- 
rent pain,  urine  in  less  quantity  than  when  in  health,  and  occasion- 
ally tinged  with  blood.  The  cause  of  the  eclampsia  was  therefore 
probably  a  vesical  calculus.  Various  remedies  were  made  use  of 
till  Februarj^  1st,  without  diminution  in  the  severity  or  frequency 
of  the  attacks  ;  when  bromide  of  potassium  was  prescribed  in  half- 
grain  doses  every  six  hours.  From  February  1st  to  3d  there  were 
two  convulsions  daily.  On  the  3d  the  medicine  w^as  given  every 
.three  hours,  after  which  there  was  no  further  eclampsiji.  The 
medicine  was  discontinued  on  the  7th.  The  infant  nursed  as 
usual,  and  its  health  seemed  to  be  re-established,  wath  the  excep- 
tion of  those  symptoms  which  indicated  the  presence  of  a  calculus. 
Examination  of  the  bladder  for  stone  was  deferred  for  a  few  days, 
when,  about  two  weeks  subsequently  to  the  last  convulsion,  the 
infant  died  suddenly  and  unexpectedly.  Though  the  result  of  this 
case  was  unfavorable,  the  controlling  power  of  the  bromide  over 
the  eclampsia  was  apparent. 

Those  children  who  are  subject  to  eclampsia  from  trifling  causes, 
and  sometimes  w^ithout  apparent  cause,  while  their  general  health 
is  good,  are  more  benefited  by  bromide  of  potassium  than  by  any 
other  medicine.  The  etficacy  of  the  bromide  in  epileps}-  is  well 
known,  and  in  all  those  cases  of  eclampsia  which  aj)proximate 
epilepsy,  and  in  which  it  is  feared  that  the  child  will  become  ejii- 
leptic,  this  agent  is  preferable  to  all  others.  It  may  be  given  in 
doses  of  one  grain  to  a  child  one  year  old,  every  three  to  six  hours, 
and  an  additional  half  grain  or  grain  for  every  subsequent  year. 

R.  Potass,  bromid.  gr.  xvj  ; 
Saccli.  alb.  5ss ; 
Aq.  anisi  §ij. 
Dose,  one  teaspoonfiil  every  three  to  six  hours,  to  a  child  of  one  year. 

The  treatment  of  eclampsia  obviously  should  vary  in  different 
cases,  according  to  the  cause.  If  it  occur  in  an  eruptive  fever,  as 
scarlatina,  and  the  eruption  has  receded,  active  revulsive  mea- 
sures, as  hot  mustard-baths,  are  required ;  if  in  dysentery,  or  other 
internal  inflammation,  sinapisms  should  be  applied  over  the 
affected  part;  if  the  gums  are  swollen,  and  the  eclampsia  is  not 
readily  controlled  by  the  ordiuary  measures,  they  should  be 
scarified.     In  those  dangerous  cases  in  which  symptoms  of  cerebral 


382  TETANUS    INFANTIUM. 

congestion  continue  after  tHe  eclampsia  ceases,  additional  treat- 
ment is  required.  The  child  remains  drowsy,  does  not  speak,  or 
apparently  suiter  in  any  way,  and  the  pupils  act  less  readily 
than  in  health.  If  this  condition  remains  after  the  lapse  of  a 
few  hours,  there  is  probably  serous  eftusion.  All  attacks  of 
eclampsia,  unless  the  mildest,  are  followed  by  a  period  of  drowsi- 
ness, but  the  persistence  of  it,  with  symptoms  which  indicate 
hyperemia,  with  perhaps  eifusion  within  the  cranium,  calls  for  the 
employment  of  additional  measures.  Vesication  should  then  be 
produced  behind  the  ears,  mild  revulsives  be  applied  to  the  extre- 
mities, the  head  kept  cool,  the  bowels  ojaen,  and,  in  certain  cases,  a 
diuretic  like  iodide  of  potassium  may  be  advantageously  employed. 
The  utmost  care  should  be  enjoined  in  reference  to  the  hygienic 
management  of  those  who  are  subject  to  eclampsia.  The  diet 
should  be  nutritious,  but  bland,  and  all  causes  of  excitement  be 
studiously  avoided. 


CHAPTER  XTI. 

TETANUS  INFANTIUM. 

Tetanus  or  trismus  is  one  of  the  most  interesting  diseases  of 
infancy.  It  is  lirst,  in  point  of  time,  in  the  long  catalogue  of  fatal 
maladies.  It  occurs  suddenly  and  unexpectedly  in  the  robust  as  well 
as  feeble,  almost  certainly  destroying  life  within  a  few  hours  under 
modes  of  treatment  heretofore  employed.  It  is  more  frequent  in 
some  localities  and  conditions  of  life  than  in  others.  In  New  York 
it  is  more  common  than  tetanus  at  any  other  age,  or,  indeed,  in  all 
other  ages,  since  the  mortuary  statistics  of  this  city  exhibit  a  larger 
number  of  deaths  from  this  disease  in  the  first  year  of  life  than 
subsequently.  Infantile  tetanus  occurs,  with  very  few  exceptions, 
in  the  new-born. 

Interesting  and  important  as  is  tetanus  infantium,  it  must  be 
confessed  that  our  knowledge  of  it  is  much  more  limited  and 
imperfect  than  it  should  be,  when  we  consider  what  great  advance- 
ment has  been  made  in  pathological  inquiries  during  the  present 
century.  Our  information  in  reference  to  its  causation,  symptoais, 
and  proper  treatment  is  not  much  in  advance  of  that  of  M.  Dazille, 
or  Dr.  Joseph  Clarke,  who  lived  in  the  latter  part  of  the  last 
century. 

Did  we  better  understand  the  pathology  of  diseases  in  the  new- 
born, or   could  we   more   accurately  ascertain   the   condition   of 


CASES.  383 

organs  ut  this  age,  doul)tlcss  we  should  occasionally  consider  those 
})henonKMia  which  we  now  designate  as  a  disease  per  6'c,  under  the 
title  tetanus,  as  symptoms  of  some  other  aftection.  But  as  tetanic 
rigidity  and  spasms  in  the  now-born  occur  so  abruptly,  masking 
all  other  symptoms,  and  ordinarily  ending  in  death  without  our 
knowing  certainly  whether  or  not  there  is  any  antecedent  disease, 
it  seems  eminently  proper  that  we  should  recognize  the  state  in 
which  such  muscular  rigidity  occurs  with  such  a  rapid  result  as 
an  independent  affection.  This  explanation  is  required  from  the 
fact  that  I  have  added  to  the  accompanying  table  one  case  from 
Billard,  which  this  observer  relates  under  the  head  of  spinal 
meningitis.  In  this  case,  an  infant  three  days  old  was  attacked 
with  convulsions.  "His  limbs  were  rigid  and  violently  bent;  the 
muscles  of  the  face  were  in  a  continual  state  of  contraction."  On 
the  following  day  "  the  convulsions  continued ;  .  .  .  the  body 
remained  rigid,  and  the  vertebral  column,  which  the  weight  of  the 
trunk  will  cause  to  bend  with  the  greatest  ease  in  a  young  infant, 
remained  straight  and  immovable  whenever  the  child  was  raised." 
At  the  autops}',  in  addition  to  meningeal  apoplexy,  which  is  often 
present  in  those  who  die  of  tetanus  infantium  a  thick  pellicular 
exudation  was  found  upon  the  spinal  arachnoid.  There  is,  there- 
fore, a  strict  accordance  of  the  symptoms  and  history  of  this  case 
with  those  which  other  observers  describe  as  examples  of  tetanus 
infantium ;  moreover,  as  a  satisfactory  reason  for  including  this 
case  in  our  statistics,  certain  eminent  observers,  as  we  will  see,  have 
reported  epidemics  of  tetanus  in  which  meningitis  was  the  princi- 
pal lesion. 

Fatal  Cases. 

Case  1.  Male;  taken  when  three  days  old;  lived  sixt}^  hours.     Labatt, 
Edin.  Med.  and  Surg.  Jourri.,  April,  1819. 
Female;  taken  when  three  days  old;  lived  forty  hours.     Ibid. 
Taken  when  five  days  old;  lived  fifty  hours.      Ibid. 
Taken  when  three  days  old  ;  lived  one  da3\     Ibid. 
Male;   taken  when  two  days  old;    lived    two  daj's.      Billard, 

Treatise  on  Diseases  of  Children,  Stewart's  trans.,  p.  471. 
Male;  taken  when  three  days  old;  lived  two  days.     Romberg. 
Male;  taken  when  six  days  old;  lived  ninety-three  hours.     Dr. 
Imlach,  Month.  Journ.  of  Med.  Sci.,  Aug.  1850. 
"     8.  Female;  taken  at  five  days;  lived  four  days.    Caleb  Woodworth, 

M.D.,  Boston  Med.  and  Surg.  Journ.,  Dee.  13,  1831. 
"     9.  Negro;  taken  at  seven  days;  lived  twenty-four  hours.     P.  C. 
Gaillard,  M.D.,  South.  Journ.  of  Med.  and  Fhar.,  Sept.  1846. 
"  10.  Male;  taken  when  seven  days  old;  lived  one  day.     Augustus 
Eberle,  M.D.,  Missouri  Med.  and  Surg.  Journ.,  1847. 


(( 

2. 

(I 

3. 

(( 

4. 

u 

5. 

u 

6. 

u 

7. 

384  TETANUS    INFANTIUM. 

Case  11.  Taken  when  seven  days  old.      D.  B.  Nailer,  N.  0.  Med.  Journ.^ 

Nov.  1846. 
"  12.  Male;  taken  when  three  days  old;  lived  one  day.     N.  0.  Med. 

and  Surg.  Joiirn.,  Maj',  1853. 
"  13.  Negro  ;  taken  when  three  days  old;  lived  three  days.     Robert 

H.  Chinn,  M.D.,  N.  0.  Med.  and  Surg.  Journ. 
"  14.  Taken  when  two  days  old  ;  died  in  four  hours  after  the  doctor's 

visit.     Ibid. 
"  15.  Taken  when  seven  days  old;  lived  one  day.     C.  11.  Cleaveland, 

Neio  Jersey  Med.  Rep..,  April,  1852. 
"  16.  Negro;  taken  when  seven  days  old;  death  finall}'.     Greenville 

Dowell,  Amer.  Journ.  of  Med.  Sci.,  Jan.  1863. 
"  17.  Taken  when   twelve   days  old;    lived    one   day.      Thomas  C. 

Boswell  communicated  to  Dr.  Sims,  Amer.  Journ.  of  Med. 

Sci.,  1846. 
"  18.  Taken  when  about  five  days  old;  died  at  about  the  age  of  nine 

days.     B.  R.  Jones.     Ibid. 
"  19.  Taken  at  or  soon  after  birth  ;  lived  two  days.     Dr.  Hims,  Amer. 

Journ.  of  Med.  ScL.  April,  1846. 

20.  Taken  at  the  age  of  six  days ;  lived  one  day.     Ibid. 

21.  Taken  when  three  days  old;  lived  two  days.     Ibid. 

22.  Male;   taken  at  the  age  of  eight  daj's;    died  in  three  hours. 
Communicated  to  the  writer. 

23.  Talven  at  the  age  of  twelve  hours ;  lived  two  days.     Communi- 
cated to  the  wa-iter. 

24.  Female;    taken  when  seven  days  old;    lived  forty-five  hours. 

The  writer. 
"  25.  Male;  taken  at  the  age  of  seven  days;  lived  about  fortj'-eight 

hours.     Ibid. 
"  26.  Female ;   taken  at  the  age  of  eight  days ;    lived  three  days. 

Ibid. 
"  21.  Female;  taken  at  the  age  of  five  days;  lived  three  daj^s.     Ibid. 
"  28.  Female ;  taken  when  four  da3^s  old ;  lived  tw^o  days.     Ibid. 
"  29.  Taken  when  six  days  old  ;  died  next  da}'.     Ibid. 
"  30.  Taken  when  five  days  old  ;  lived  twenty-four  hours.     Ibid. 
"  31.  Taken  when  eight  days  old ;  lived  two  days.     Ibid. 
"  32.  Male;  taken  when  five  daj's  old;  lived  one  day.     Ibid. 

Favorable  Cases. 

Case  1.  Negro;  female;  taken  when  three  days  old;  recovered  in  a  few 
days.  Robert  S.  Baily,  Charleston  Med.  Journ.  and  Rev.., 
Nov.  1848. 

"  2.  Negro ;  taken  at  eleven  days ;  recovered  in  fifteen  days.  W. 
B.  Lindsay,  N.  0.  Med.  Journ..,  Sept.  1846. 

"  8.  Negro;  taken  when  ten  days  old;  recovered  in  thirty-one  days. 
P.  C.  Gaillard,  Charleston  Med.  Journ.  and  Rev..,  Nov.  1853. 

"  4.  Male ;  taken  at  the  age  of  eight  days ;  recovered  in  twenty-eight 
days.     Ibid. 

"  5.  Negro;  taken  at  seven  days;  recovered  in  fifteen  days.  Au- 
gustus Eberle,  Missouri  3Ied.  and  Surg.  Journ.,  184Y. 

"  6.  Taken  when  eight  days  old;  recovered  in  four  weeks;  Furlong, 
Edin.  Med.  and  Surg.  Journ.,  Jan.  1830. 


a 


^-u 


FREQUENCY    IN    CERTAIN    LOCALITIES.  385 

Case  T.  Taken  at  the  age  of  one  week;   recovered  in  two  days.     Dr. 
Sims,  Amer.  Journ.  of  Med.  Sci.,  April,  1846. 
"     8.  Female ;  taken  at  the  age  of  three  days;  recovered  in  five  weeks. 
The  writer. 

Period  of  Commencement. — Finckh,  who  saw  cases  of  tetanus  of 
the  new-born  in  the  Stuttgart  Hospital,  states  {Hecker's  Annalen, 
vol.  ill.  No.  3,  p.  304)  that  it  began  in  one  case  on  the  second  day 
after  birth,  in  eight  on  the  fifth,  and  in  seven  on  the  seventh. 

Professor  Cederschjold,  of  Stockholm,  treated  forty-two  cases 
in  hospital  practice  in  1834,  and  in  these  cases  it  usually  com- 
menced between  the  ages  of  four  and  six  days.  Copland  says  [3Iedi- 
cal  Dictionary)  that  it  generally  commences  in  the  first  seven  or 
nine  days  after  birth,  and  rarely  later  than  the  fourteenth.  Rom- 
berg states  that  it  commences  between  the  fifth  and  ninth  days. 
In  two  hundred  cases  observed  by  Reicke,  in  Stuttgart,  in  the 
course  of  forty -two  years,  it  was  never  found  to  commence  before 
the  fifth,  rarely  after  the  ninth,  and  never  after  the  eleventh  day. 
Schneider  says  that  the  disease  occurs  oftenest  between  the  second 
and  seventh,  and  rarely  after  the  ninth  day.  In  six  cases  reported 
by  Dr.  C.  Levy,  of  Copenhagen,  it  began  in  two  on  the  third  day, 
in  two  on  the  fifth,  and  in  two  on  the  sixth.  Dr.  Greenville 
Dowell  {Amer.  Journ.  of  Med.  Sci..,  Jan.  1863),  who  has  seen  much 
of  tetanus  infantum  among  the  negroes  in  Mississippi  and  Texas, 
says  it  is  almost  sure  to  come  on  between  the  fifth  and  twelfth 
days  after  birth.  In  the  forty  cases  embraced  in  the  above  table, 
the  disease  began  as  follows : — 


Age. 

Cases. 

Age. 

Cases 

One  day  or  imder    . 

.     3 

Seven  days 

.     8 

Two  days 

.     1 

Eight     " 

.     6 

Three  " 

.     9 

Ten 

.     1 

Four    "           .        . 

.     2 

Eleven  " 

.     1 

Five     " 

.     6 

Twelve  " 

.     1 

Six       " 

.     3 

Very  rarely,  as  will  be  seen  hereafter,  tetanus  begins  at  or  soon 
after  birth,  that  it  may  be  properly  called  congenital. 

Frequency  in  Certain  Localities. — Tetanus  infantum  occurs 
probably  in  all  countries,  but  it  does  not  greatly  increase  the  mor- 
tality except  in  certain  localities.  Some  of  the  British  and  conti- 
nental physicians  whose  observations  of  disease  have  been  ample, 
confess  that  they  have  seen  so  few  cases  that  they  have  almost  no 
personal  knowledge  of  this  aftection.  On  the  other  hand,  there 
are,  or  have  been,  places  in  every  zone  where  it  is  or  has  been  so 
25 


386  TETANUS    INFANTUM. 

prevalent  as  to  sensibly  check  the  increase  of  population.  The 
attention  of  the  profession,  more  than  half  a  century  since,  was 
directed  to  the  prevalence  of  tetanus  in  the  Island  of  Heimacy,  off 
the  coast  of  Iceland.  On  this  island  scarcely  an  infant  escaped, 
while  on  the  mainland  scarcely  one  was  affected.  Heimacy,  the 
product  of  volcanic  action,  of  small  extent  and  almost  destitute  of 
vegetation,  supports  a  scanty  pojDulation.  The  inhabitants  live 
chiefly  on  the  flesh  and  eggs  of  the  sea-fowl,  and  are  filthy  and 
degraded  in  their  habits.  About  the  year  1810,  the  Danish 
government  deputed  the  landphysicus  of  Iceland  to  visit  Heimacy, 
and  ascertain  the  nature  of  the  disease  which  was  so  destructive  to 
the  infants.  Although  this  gentleman,  from  his  brief  stay,  saw  no 
case  himself,  he  obtained  interesting  particulars  in  reference  to  the 
disease  from  the  priests  and  parents.  At  this  time  scarcely  an 
infant  escaped.  Again,  according  to  Dr.  Schleisner,  whose  report 
in  reference  to  the  same  locality  was  published  forty  years  later, 
this  disease  was  still  the  most  fatal  of  all  infantile  affections. 

Tetanus  infantum  is  also  represented  as  very  fatal  in  the  Island 
of  St.  Kilda,  off  the  coast  of  Scotland.  In  the  temperate  regions 
of  America  and  Europe  cases  are  not  frequent,  except  occasionally 
in  the  poor  quarters  of  the  cities,  in  foundling  hospitals,  and 
rarely  in  country  towns  where  the  conditions  are  favorable  for 
its  occurrence.  The  records  of  the  Dublin,  Stuttgart,  and  Stock- 
holm lying-in  asylums  furnish  many  cases.  In  the  town  of 
Fulda,  Germany,  in  1802,  Dr.  Schneider  saw  six  cases  in  fourteen 
days,  while  a  midwife  in  the  same  place  stated  that  she  had  seen 
more  than  sixty  in  nine  years. 

But  the  greatest  mortality  from  tetanus  infantum  is  in  the  warm 
climates,  both  of  the  Eastern  and  Western  Hemispheres.  In  the 
AVest  Indies,  the  southern  portion  of  the  United  States,  the  equa- 
torial regions  of  South  America,  and  in  the  islands  of  Minorca 
and  Bourbon,  it  has,  in  many  localities,  been  the  most  frequent 
and  fatal  of  infantile  maladies. 

It  is  an  interesting  fact  that  in  the  warm  regions  of  the  United 
States  the  victims  are  chiefly  negro  infants.  L.  S.  Grier,  M.D.,  of 
Mississippi,  says,  in  the  N.  0.  Med.  and  Surg.  Journ.^  May,  1854  : 
"The  first  form  of  disease  which  assails  the  negro  among  us  is 
trismus.  The  mortality  from  this  disease  alone  is  very  great,  l^o 
statistical  record,  we  suppose,  has  even  been  attempted,  but  from 
our  individual  experience  we  are  almost  willing  to  affirm  that  it 
decimates  the  African  race  upon  our  plantations  within  the  first 
week  of  independent  existence.     We  have  known  more  than  one 


CAUSES.  387 

instance  in  which,  of  the  births  for  one  year,  one-half  became  the 
victims  of  this  disease,  and  that,  too,  in  spite  of  the  utmost  watcli- 
fuhicss  and  care  on  the  part  of  both  planter  and  physician.  Other 
places  are  more  fortunate,  but  all  suffer  more  or  less  ;  and  the 
planter  who  escapes  a  year  without  having  to  record  a  case  of  tris- 
mus nascentium  may  congratulate  himself  on  ])eing  more  favored 
than  his  neighbors,  and  prepare  himself  for  his  own  allotment, 
which  is  surely  and  speedily  to  arrive."  Dr.  Wooten  (iV.  0.  Med. 
and  Surg.  Journ.,  May,  1846)  says:  "It  is  a  disease  of  fatal  fre- 
quency on  the  cotton  plantations  in  this  section  of  Alabama." 
He  has,  however,  never  seen  a  white  child  affected  with  it. 

In  I^ew  Orleans,  according  to  the  death  statistics  in  our  posses- 
sion, which,  however,  relate  to  only  one  year,  tetanus  infantum 
is  the  most  fatal  of  all  diseases  except  phthisis.  Mr.  Maxwell 
says,  in  the  Jamaica  Physical  Journal  (copied  in  the  Lo7idon  Lancet., 
April  11th,  1835):  "From  observations,  that  I  have  made  for  a 
series  of  years,  ...  I  found  that  the  depopulating  influence  of 
trismus  neonatorum  was  not  less  than  twenty-five  per  cent.  It 
scarcely  has  a  parallel  within  the  bills  of  mortality."  This  gentle- 
man's observations  relate  to  the  "West  Indies.  Similar  statements 
are  made  in  reference  to  this  disease  as  it  occurs  in  Cayenne  and 
Demerara  in  South  America. 

While  tetanus  infantum  prevails  in  regions  wide  apart,  and 
presenting  very  diverse  climatic  conditions,  there  is  a  similarity 
as  regards  the  personal  and  domiciliary  habits  of  the  people  who 
suffer  most  from  its  occurrence.  It  occurs  chiefly  among  those 
who  are  filthy  and  degraded  in  their  habits,  who  live,  either  from 
choice  or  necessity,  in  neglect  of  sanitary  requirements.  This  fact 
aids  us  in  an  understanding  of  the 

Causes. — That  uncleanliness  and  impure  air  are  a  cause  of 
tetanus  is  as  fully  demonstrated  as  most  facts  in  the  etiology  of 
diseases.  The  attention  of  the  profession  was  forcibly  directed  to 
this  cause  by  Dr.  Joseph  Clarke  in  a  paper  read  before  the  Royal 
Irish  Academy  in  1789.  This  physician  was  in  charge  of  the 
Dublin  Lying-in  Asylum,  and  had  rightly  concluded  that  the 
mortality  among  the  new-born  infants  was  due  to  imperfect  venti- 
lation. Through  his  advice,  apertures,  twenty-four  inches  by  six, 
were  made  in  the  ceiling  of  each  ward;  three  holes,  an  inch  in 
diameter,  were  bored  in  each  window-frame;  the  upper  part  of 
the  doors  leading  into  the  gallery  were  also  perforated  with  sixteen 
one-inch  apertures,  and  the  number  of  beds  was  reduced.  The 
result  of  these  simple  sanitary  regulations  may  be  seen  from  Dr. 


888  TETANUS    INFANTUM. 

Clarke's  own  statement.  He  says:  "At  the  conclusion  of  the  year 
1782,  of  17,650  infants  born  alive  in  the  Lying-in  Hospital  of  this 
city,  2944  had  died  within  the  first  fortnight,  that  is,  nearly  every 
sixth  child."  The  disease  in  nineteen  cases  out  of  twenty  was 
tetanus.  After  the  wards  were  better  ventilated,  namely,  from 
1782  till  the  time  of  the  preparation  of  Dr.  Clarke's  paper,  8033 
children  Avere  born  in  the  hospital,  and  only  419  in  all  had  died, 
or  about  one  in  nineteen.  So  impressed  was  Dr.  Evory  Kennedy, 
who  at  a  later  period  had  charge  of  the  same  asylum,  with  the 
belief  that  Dr.  Clarke  had  discovered  the  true  cause,  and  had  been 
able  in  a  great  measure  to  jirevent  it,  that  he  writes  in  his  enthu- 
siastic way :  "  If  we  except  Dr.  Jenner,  I  know  of  no  physician 
who  has  so  far  benefited  his  species,  making  the  actual  calculation 
of  human  life  saved  the  criterion  of  his  improvements."  The 
cases  occurring  in  my  own  practice  were  all  met  in  tenement- 
houses  or  shanties,  where  habits  of  cleanliness  are  impossible, 
and  I  have  not  yet  seen,  in  the  practice  of  others,  nor  heard  of  a 
case  which  occurred  in  the  better  class  of  domicils.  The  statements 
of  physicians  in  the  southern  States,  who  speak  from  extensive 
observation  among  the  negroes,  are  strongly  corroborative  of  the 
idea  that  the  disease  is  in  great  measure  due  to  uncleanliness  and 
impure  air. 

Dr.  Greenville  Dowell,  of  Texas,  states  that  he  has  been  able  to 
trace  the  disease  to  the  old  bedclothes,  saturated  with  excrementi- 
tious  matters,  which  are  found  in  the  negro  cabins.  In  a  paper 
published  in  the  Nashville  Journ.  of  Med.  and  Surg.,  June,  1851,  by 
Prof.  John  M.  Watson,  the  frequency  of  this  disease  among  the 
negroes  is  accounted  for  as  follows: — 

"When  called  to  see  their  children,  we  find  their  clothes  wet 

around  their  hips,  and  often  up  to  their  armpits,  with  urine 

The  child  is  thus  presented  to  us,  when,  on  examination,  we  find 
the  umbilical  dressings  not  only  wet  with  urine,  but  soiled,  like- 
wise, with  fpeces,  freely  giving  oft'  an  ofliensive  urinous  and  frecal 
odor,  combined  at  times  with  a  gangrenous  fetor  arising  from  the 
decomposition,  not  desiccation,  of  the  cord." 

Another  cause  is  believed  to  be  some  irritation  in  the  bowels, 
iis  from  retained  meconium.  Observers  in  the  southern  States  and 
elsewhere  occasionally  mention  this  as  a  cause.  In  one  case 
treated  by  myself,  there  was  obstinate  constipation  immediately 
before  the  attack,  and  in  another  diarrhoea  preceded,  and  was  the 
only  apparent  cause. 

In  certain  cases  the  assignable  cause  is  exposure  to  wet  or  cold,  or 


CAUSES.  389 

to  a  variable  temperature,  which,  it  is  known,  occasionally,  causes 
tetanus  in  the  adult.  Prof.  Ceclerschjold  attributed  the  epidemic 
which  he  observed  in  Stockholm  to  a  sudden  change  of  temperature, 
from  hot  weather  in  May,  to  frosty  in  June.  In  a  case  related  by 
Dr.  P.  C.  Gaillard,  in  the  Southern  Journ.  of  Med.  and  Pharmacy^ 
Sept.  1846,  the  disease  commenced  as  follows:  The  nurse  came  in 
with  wet  apron  and  clothes,  in  the  evening;  a  short  time  after  she 
had  taken  the  child  into  her  lap,  it  sneezed  violently  two  or  three 
times.  At  10  P.  M.  tetanus  began.  In  certain  localities  on  the 
continent,  where  there  are  no  parish  churches,  the  frequent  occur- 
rence of  tetanus  has  been  attributed  by  the  physicians  to  the 
practice  of  carrying  the  infants  to  a  distance  to  be  christened,  thus 
exposing  them  to  the  wind  and  often  rain.  Even  in  this  city  I 
have  observed  the  same  cause.  The  influence  of  the  weather  in 
the  production  of  tetanus  of  the  new-born  is  also  shown  by  facts 
observed  in  the  Stuttgart  Hospital.  In  an  aggregate  of  twenty- 
five  cases  treated  in  that  institution,  all  but  three  occurred  in  the 
cold  months.  In  the  island  of  Cayenne,  at  a  hamlet  surrounded 
by  mountains  and  dense  forests,  tetanus  attacked  only  one  in 
everj^  twelve  or  fifteen  of  the  infants.  After  a  great  part  of  the 
forests  had  been  cut  down,  so  as  to  allow  access  to  the  cold  sea 
winds,  almost  all  the  new-born  infants  fell  victims  to  tetanus. 
(Insel,  Cayenne.) 

Hein  relates  that  a  citizen  of  Berlin  lost,  successively,  two 
children  with  tetanus  soon  after  birth.  When  the  second  child  fell 
ill,  he  observed  that  its  cradle  was  exposed  to  a  current  of  air. 
At  the  third  accouchement  the  position  of  the  cradle  was  changed, 
and  the  infant  escaped.  Exposure  to  wet  and  cold  has  been  long 
recognized  as  a  cause  of  the  disease.  According  to  Sauvages, 
"Hie  morbus  hieme  et  cum  aura  humida  ssepius  advenit  quam 
sicca  restate."     (Nosol.  Method,  vol.  i.  p.  531.) 

The  causes  of  infantile  tetanus,  enumerated  above,  may  be  proxi- 
mate or  remote,  may  produce  the  disease  by  their  direct  effect 
on  the  system  or  by  producing  a  pathological  state  which  in 
turn  leads  to  the  development  of  the  disease.  There  are  other 
direct  causes,  namely,  organic  affections.  In  the  bodies  of  those 
who  die  of  this  disease  lesions  are  observed  which  doubtless  result 
from  the  spasms.  Again,  others  are  found,  which,  from  their 
nature,  could  not  be  a  result,  and  which,  being  observed  in  different 
cases,  are  to  be  regarded  as  direct  causes.  The  most  frequent  of 
such  lesions  is  inflammation  of  the  umbilicus  or  umbilical  vessels. 

Moschion,  who  lived  in  the  first  century  of  the  Christian  era, 


390  TETANUS    INFANTUM. 

stated  in  writinojs  still  extant  that  stagnant  blood  in  the  umbilical 
vessels  sometimes  produced  dangerous  disease  in  the  new-born 
infant,  and  it  is  supposed,  though  this  is  doubtful,  that  he  referred 
to  tetanus.  In  modern  times  the  attention  of  the  profession  was 
more  particularly  directed  to  this  cause  by  a  paper  j^ublished  by 
Dr.  Colles,  in  the  first  volume  of  the  Dublin  Hospital  Re-ports^  in 
1818.  The  observations  published  in  this  paper  were  made  in 
the  Dublin  Lying-in  Hospital  during  the  period  of  five  years.  In 
each  of  these  years  he  had  witnessed  from  three  to  five  post-mortem 
examinations  in  cases  of  infantile  tetanus,  and  the  lesions,  he 
states,  were  in  all  much  alike  as  follows :  The  floor  of  the  umbilical 
fossa  was  lined  by  a  membrane  apparently  formed  by  suppurative 
inflammation,  and  in  the  centre  of  this  fossa  was  a  large  papilla. 
This  papilla  consisted  of  a  soft  yellow  substance,  apparently  the 
product  of  inflammation,  and  in  all  the  cases  the  umbilical  vessels 
were  in  contact  with  this  substance  and  were  pervious.  In  a  few 
instances  superficial  ulcerations  were  found  near  the  mouth  of  the 
umbilical  vein,  and  occasionally  the  skin  surrounding  the  umbilicus 
was  raised.  The  peritoneum  covering  the  vein  was  highly  vascular, 
often  not  to  a  greater  distance  than  an  inch  above  the  umbilicus, 
but  sometimes  as  far  as  the  fissure  of  the  liver.  The  peritoneum 
in  the  course  of  the  umbilical  arteries  presented  the  inflammatory 
appearance  in  still  greater  degree  sometimes  as  far  as  the  sides  of 
the  bladder.  The  connective  tissue  lying  along  the  arteries  and 
urachus  anteriorly  was  loaded  with  a  yellow  watery  fluid.  The 
inner  surface  of  the  umbilical  vein  was  not  inflamed,  but  its  coats, 
in  general,  were  thickened.  On  slitting  open  the  arteries,  a  thick 
yellow  fluid,  resembling  coagulable  lymph,  was  found  within  their 
coats,  and  in  all  cases  these  vessels  were  thickened  and  hardened 
as  far  as  the  fundus  of  the  bladder. 

Dr.  Finckh,  who  observed  twenty-five  cases  in  the  Stuttgart 
Hospital,  believes  that  the  most  frequent  cause  was  suppuration 
or  ulceration  of  the  umbilical  cord.  In  ten  of  the  twenty-five 
cases  the  navel  was  dry  and  cicatrized;  in  the  remainder  it  was 
either  wet  or  swollen,  with  a  bluish-red  inflamed  edge  at  the 
margin  of  the  navel;  a  dirty  viscid  pus  covered  the  umbilical 
depression. 

Dr.  Levy,  physician  of  the  Foundling  Hospital  in  Copenhagen, 
attended  twenty-two  cases  in  that  institution  in  1838  and  '39. 
Of  these,  twenty  died,  and  fifteen  were  examined  carefully  after 
death.  In  fourteen  there  were  decided  marks  of  inflammation  in 
the  umbilical  arteries,  especially  those  portions  lying  along  the 


CAUSES.  391 

urinary  bladder;  in  several  cases  the  peritoneum  over  the  arteries 
was  much  injected,  and  in  three  adherent  either  to  the  omentum 
or  intestine  by  coagulable  lymph ;  the  coats  of  the  arteries  were 
thickened,  their  cavities  dilated  and  containing  dark  reddish-brown 
or  greenish  puriform  matter,  always  fetid.  Sometimes  the  arterial 
tunica  interna  was  found  ulcerated  and  absent  in  places,  and  there 
was  spongy  thickening  of  the  subjacent  connective  tissue.  In  two 
cases  the  ulcerative  process  had  extended  from  the  tunica  interna 
to  the  peritoneum,  and  there  was  a  deposit  of  thick  ichorous 
matter  around  the  ulcer ;  in  one  case  both  arteries  were  so  softened 
that  their  coats  were  scarcely  distinguishable,  and  in  another  these 
vessels  had  become  gangrenous.  The  appearance  of  the  umbilicus 
was  unchanged  in  four  cases ;  in  ten  the  fundus  was  red  and  filled 
with  puriform  fluid,  which  quickly  reappeared  when  removed, 
and,  in  general,  shortl}^  before  death  the  navel  presented  a  greenish 
color. 

According  to  Romberg,  Dr.  Scholler  made  post-mortem  examina- 
tions in  eighteen  cases  of  tetanus  infantum,  and  in  fifteen  found 
inflammation  of  the  umbilical  arteries.  These  vessels  were  swollen 
near  the  bladder,  in  one  case  to  the  diameter  of  four  lines,  and  were 
found  to  contain  pus.  The  lining  membrane  was  eroded  or  covered 
with  an  albuminous  exudation.  Both  arteries  were  not  always 
equally  inflamed,  and  in  three  cases  only  one  was  aflfected. 

Schneeman  found  minute  points  of  suppuration  in  the  umbilical 
vein  in  eight  cases  {Holscher''s  Annalen^  vol.  v.  p.  484,  1840),  and 
pus  throughout  the  course  of  this  vessel  in  one. 

The  observations  mentioned  above  were  made,  for  the  most  part, 
in  hospitals  on  the  Continent ;  but  similar  observations  have  been 
made  in  private  practice.  M  Boiran,  of  the  Isle  of  Bourbon,  says 
that  he  has  found  in  every  case  inflammation  around  the  umbilicus 
{Gazette  Medicate,  Paris,  July  11,  1841).  Dr.  John  Furlonge 
{Edin.  Med.  and  Surg.  Jourji.,  Jan.  1830),  who  resided  at  St. 
John's,  Antigua,  attributes  the  disease  to  improper  dressing  of  the 
umbilicus.  The  same  opinion  is  expressed  by  Mr.  Maxwell,  who 
also  saw  the  disease  in  the  West  Indies  (Jamaica  Phys.  Joiirn., 
copied  into  the  London  Lancet.,  April  11,  1855).  Dr.  Ransom 
states,  in  a  communication  to  Prof.  John  M.  Watson  {Nashville 
Journ.  of  Med.  and  Surg.,  June,  1851)  that  he  has  never  seen  a  case 
of  tetanus  of  the  new-born  in  which  the  umbilicus  was  healthy. 
In  a  case  related  by  Robert  S.  Baily,  in  the  Charleston  Med.  Journ. 
and  Rev.,  l^ov.  1848,  there  was  a  hard  scab  on  one  side  of  the 
umbilicus,  and  this  part  was  much  distended.     A  discharge  fol- 


292  TETANUS    INFANTUM, 

lowed  the  removal  of  the  scah,  and  the  child  recovered.  In  a 
favorable  case,  related  by  W.  B.  Lindsay,  in  the  N.  0.  Med.  and 
Surg.  Joiirn.,  Sept.  1846,  the  umbilicus  was  tumid,  and  not  disposed 
to  heal.  Dr.  II.  0.  Wooten  (same  journal.  May,  1846)  attributes 
the  disease  to  the  condition  of  the  umbilicus  and  umbilical  vessels, 
and  states  that  he  has  found  the  umbilicus  gangrenous.  In  a  case 
related  in  the  N.  0.  Med.  and  Surg.  Jour7i.,  May  1,  1853,  the  um- 
bilical vessels  were  blocked  up  by  purulent  matter.  Robert  A. 
Chime,  M.D.,  Brazoria,  Texas  {N.  0.  Med.  and  Surg.  Jouni.,  Sept. 
1854),  believes  one  cause  of  the  disease  to  be  improper  tying  and 
management  of  the  umbilical  cord,  by  which  a  diseased  state  is 
produced,  which  extends  to  the  umbilicus,  and  thence  to  the  vis- 
cera. At  a  meeting  of  the  Obstetrical  Society  of  Edinburgh,  held 
April  24,  1850,  Dr.  Imlach  related  a  case  in  which  there  was  a  dark 
and  gangrenous  appearance  of  the  integument  around  the  um- 
bilicus, and  the  peritoneum  underneath  was  also  dark,  but  not 
inflamed ;  umbilical  vein  healthy ;  a  little  fibrin  in  the  left  um- 
bilical artery;  right  umbilical  artery  much  diseased;  its  two  inner 
coats  apparently  destroyed,  and  in  their  place  a  yellow  pultaceous 
slough,  in  which  pus-globules  were  discovered  with  the  micro- 
scope. 

It  is  evident  that  the  pathological  state  of  the  umbilicus  and 
umbilical  vessels  described  above,  and  which  has  been  noticed  by 
so  many  observers  in  difterent  countries,  cannot  result  from  the 
tetanus.  It  is  possible  that  the  puriform  substance  noticed  in  the 
umbilical  vessels  was  disintegrated  fibrin,  which  had  coagulated 
at  the  time  of  ligation  of  the  cord,  and  the  cells  seen  by  Dr. 
Imlach  and  others  may  sometimes  have  been  white  corpuscles  still 
remaining  from  the  stagnated  blood.  {Virchow's  Cellul.  Pathol.) 
Still,  the  evidences  of  inflammation,  in  at  least  a  part  of  the  cases 
related  above,  were  of  a  positive  character. 

The  belief  that  umbilical  lesions  sometimes  cause  tetanus  in- 
fantum comports  with  the  well-known  traumatic  causation  of  teta- 
nus in  the  adult.  This  belief  is  strengthened  by  the  fact,  which 
will  appear  further  on  in  our  remarks,  that  this  disease  of  the  new- 
born, from  being  frequent  in  certain  localities,  has  become  infre- 
quent through  greater  care  in  dressing  and  managing  the  umbilical 

cord. 

But  there  are  cases  of  tetanus  infantum  in  which  there  is  no 
disease  in  or  about  the  umbilicus.  Dr.  Pinckh,  of  Stuttgart, 
examined  the  umbilical  vessels  in  eleven  cases  without  discovering 
any  pathological  change.     Dr.  Samuel  B.  Labatt,  master  of  the 


CAUSES.  39 


Q 


DulJliii  Lying-in  Hospital,  i^nblished  in  the  Edin.  3Ied.  and  Surg. 
Joujii.,  April,  1819,  a  ])[iper  entitled  "An  Inquiry  into  an  Alleged 
Connection  between  Trismus  JSTascentium  and  certain  Diseased 
Appearances  in  the  Umbilicus."  This  paper  was  designed  as  a 
reply  to  the  essay  of  Dr.  Colles.  Dr.  Labatt  relates  several  cases  in 
which  there  was  no  disease  of  the  umbilicus  and  umbilical  vessels, 
and  others  in  which  the  disease  was  so  slight  that  it  probably  pro- 
duced no  injurious  eftect  on  the  health  of  the  child.  Dr.  James 
Thompson,  who  spent  considerable  time  in  the  tropical  regions, 
says  [Edin.  3Ied.  and  Surg.  Journ.,  Jan.  1822) :  "  I  have  myself 
examined  nearlj^  forty  cases  of  infants  that  have  sunk  under  this 
complaint.  In  many  I  have  looked  at  no  other  part  but  the  navel, 
and  have  found  it  in  all  states ;  sometimes  perfectly  healed,  espe- 
cially if  the  infants  had  lived  several  days ;  at  other  times  a  simple 
clean  wound.  When  death  occurred  on  the  fifth  or  sixth  day,  the 
\vound  was  frequently  in  a  raw  state.  I  never  yet  saw"  it  in  a 
sphacelated  condition."  This  writer  concludes  from  his  observa- 
tions that  there  are  cases  in  which  the  cause  is  located  elsewhere 
than  in  the  umbilicus  or  umbilical  vessels.  In  the  Eub.  Joiirn.  of 
Med.  and  Chem  Sci.,  Jan.  1836,  Dr.  John  Breen  remarks:  "  From 
dissections  .  .  .  we  have  never  been  able  to  discover  any  peculiar 
morbid  appearance  which  would  justify  us  in  offering  any  explana- 
tion of  the  pathology  of  the  disease."  In  my  own  cases  there  was 
no  evidence  of  disease  of  the  umbilicus  or  umbilical  vessels  so  far 
as  could  be  ascertained  by  external  examination,  and  in  one  (I^o.  32) 
a  careful  post-mortem  examination  disclosed  no  lesion  of  these 
parts. 

The  inference  from  the  above  observations  is  that,  although 
umbilical  disease  may  be  an  occasional,  probably  not  infrequent, 
cause  of  tetanus  infantum,  cases  occur  in  which  such  disease  is  not 
present,  and  we  must  look  for  the  cause  elsewhere.  From  the 
nature  of  tetanus  infantum,  the  cerebro-spinal  axis  has  been  from 
time  to  time  examined  in  those  who  have  died  of  this  disease,  and 
occasionally  sufficient  cause  has  been  found  in  this  part  of  the 
system. 

I  have  alluded  in  another  connection  to  a  case  from  Billard,  in 
which  tetanic  rigidity  occurred  in  an  infant  three  days  old,  as  the 
result  of  spinal  meningitis.  That  tonic  spasms  not  infrequently 
occur  in  older  children  in  consequence  of  meningeal  inflammation 
is  well  known,  and  in  some  of  the  reported  epidemics  of  infan- 
tile tetanus  meningitis  was  really  present,  and  was  doubtless  the 
cause  of  the  tonic  spasms.      Such  an  epidemic  was  observed  by 


394:  TETANUS    INFANTUM. 

Professor  Cederschjold  in  Stockholm,  in  1834.  "Within  a  few 
months  he  treated  forty-two  cases,  and,  in  addition  to  the  lesions 
which  are  known  to  result  from  tetanus,  there  was  found  in  the 
bodies  examined  a  plastic  exudation  at  the  base  of  the  brain. 
Finckh,  of  Stuttgart,  made  twenty  post-mortem  examinations  of 
those  who  had  died  of  this  disease,  and  in  nine  found  spinal  menin- 
geal inflammation. 

Meningitis  in  the  new-born  infant  is,  however,  rare,  and  we 
must  regard  it  as  an  exceptional  cause  of  tetanus. 

In  1846  there  appeared  from  the  pen  of  Dr.  Sims,  then  practis- 
ing at  Montgomery,  Alabama,  a  paper  designed  to  show  that 
tetanus  of  the  new-born  is  produced  by  pressure  exerted  on  the  ner- 
vous centre,  through  depression  of  the  occipital  bone.  In  1848  the 
same  writer  published  a  second  paper,  also  in  the  Amer.  Journ.  of 
Med.  Sci.,  fully  enunciating  his  theory  as  follows:  "That  trismus 
neonatorum  is  a  disease  of  centric  origin  depending  on  a  mechani- 
cal pressure  exerted  on  the  medulla  oblongata  and  its  nerves;  that 
this  pressure  is  the  result,  most  generally,  of  an  inward  displace- 
ment of  the  occipital  bone,  often  very  perceptible,  but  sometimes 
so  slight  as  to  be  detected  with  difficulty ;  that  this  displaced  con- 
dition of  the  occiput  is  one  of  the  fixed  physiological  laws  of  the 
parturient  state ;  that  when  it  persists  for  any  length  of  time  after 
birth  it  becomes  a  pathological  condition,  capable  of  producing  all 
the  symptoms  characterizing  trismus  neonatorum,  which  are  in- 
stantly relieved  simply  by  rectifying  this  abnormal  displacement, 
and  thereby  removing  pressure  from  the  base  of  the  brain."  In 
both  papers  cases  are  narrated  in  support  of  this  theory,  but  there 
are  serious  objections  to  this  mode  of  explaining  the  occurrence  of 
the  disease.  In  the  first  place,  if  this  explanation  were  correct, 
tetanus  ought  ordinarily  to  occur  sooner,  for  the  occiput  is  as  much 
depressed  previously,  and  in  the  majority  of  cases  more  depressed 
than  at  the  period  when  it  does  actually  commence.  Pressure  on 
the  medulla  would  certainly  be  followed  by  immediate  and  marked 
symptoms,  instead  of  an  immunity  for  four  or  five  days. 

Again,  well-known  facts  in  reference  to  the  causation  of  teta- 
nus infantum  conflict  with  Dr.  Sims's  theory,  as,  for  example,  epi- 
demics of  the  disease,  its  prevalence  in  one  locality  and  absence  in 
another,  although  no  particular  attention  is  given  to  the  position 
of  the  infant,  the  diminution  of  the  number  of  cases  by  greater 
attention  to  cleanliness,  of  which  there  is  abundant  proof.  More- 
over, there  are  many  reported  cases  of  this  disease  at  the  commence- 


CAUSES.  395 

ment  of  which  there  was  no  perceptible  displacement  of  the  occipital 
bone. 

The  inequality  of  the  cranial  bones  often  observed  in  tetanus 
infantum  should,  in  my  opinion,  be  explained  as  follows:  When 
the  new-born  infant  becomes  emaciated,  the  volume  of  the  brain  is 
diminished,  like  that  of  the  trunk  or  limbs,  and  the  sinking  of  the 
occipital  bone  simply  corresponds  with  the  amount  of  waste  in  the 
cerebral  substance.  Whatever  the  disease  in  the  young  infant,  if 
there  is  much  emaciation,  the  parietal  bones  will  usually  be  found 
more  prominent  than  the  occipital.  Now,  in  fatal  tetanus 
infantum,  emaciation  is  very  rapid;  those  fleshy  and  plump,  if 
the  disease  do  not  speedily  end,  become  pinched  and  wrinkled. 
Viewed  in  this  light,  the  occipital  depression  should  be  regarded 
as  a  result,  and  not  cause,  of  the  tetanus. 

Although  we  do  not  accept  the  theory  which  attributes  tetanus 
infantum  to  occipital  depression,  there  are  a  few  cases  on  record 
in  which  it  was  apparently  due  to  injury  of  the  head  received  at 
birth.  Dr.  Sims  has  related  one  such  case,  that  of  a  negro  infant. 
The  mistress,  an  observing  lady,  gave  to  Dr.  Sims  the  following 

account  of  it:  Its  head  was  "mightily  mashed The  bones 

seemed  to  be  loose.  I  got  it  to  take  a  little  boiled  milk  on  the 
first  day;  but  it  swallowed  very  little  and  very  badly,  for  its  jaws 
seemed  to  be  locked.  On  the  next  day  it  took  spasms  and  got 
stiff  all  over ;  its  hands  were  shut  up  tight,  and  its  arms  were  bent 
up  so  (she  placed  her  forearms  at  right  angles).  Every  time  I 
touched  it  the  spasm  would  get  worse  all  over,  screwing  up  its  face 
till  it  was  the  ugliest  thing  in  the  world;  and  when  the  spasms 
wore  off  it  looked  as  well  as  any  other  new-born  baby.  But  then 
the  stiffness  never  left  it,  and  the  spasms  kept  coming  and  going- 
till  it  died."     It  lived  two  days. 

It  is  evident,  from  the  description  given  by  the  mistress,  that  this 
was  a  case  of  tetanus  commencing  at  or  so  soon  after  birth  that 
it  seemed  almost  congenital.  The  apparent  cause  was  injury  of 
the  head,  occurring  in  consequence  of  protracted  birth,  the  infant 
being  resuscitated  with  difiiculty  after  several  minutes. 

Dr.  W.  C.  Sutton  published  a  similar  case  in  the  Nashville  Journ. 
of  Med.  and  Surg.,  April,  1853.  The  infant  at  birth  was  apparently 
dead,  but  was  resuscitated  so  as  to  live  eighteen  hours  in  a  state  of 
tetanic  rigidity.  In  cases  in  which  tetanus  begins  at  birth,  doubt- 
less, the  cerebro-spinal  axis  is  in  some  Avay  affected ;  but  in  the  ab- 
sence of  post-mortem  examinations,  the  exact  nature  of  the  lesion 
is  uncertain. 


896  TETANUS    INFANTUM. 

It  IS  evident,  therefore,  that  in  this  disease,  as  in  eclampsia,  the 
cause  in  different  cases  may  be  entirely  distinct.  Dr.  James  John- 
son, many  years  aojo,  expressed  his  belief  in  the  multiplicity  of 
causes,  and  he  had  been  a  careful  and  intelligent  observer  in  the 
West  Indies. 

The  causes  may  be  arranged  in  two  groups,  one  external,  the 
other  internal.  In  the  first  group  should  be  placed  imperfect 
ventilation,  personal  and  domiciliary  uncleanliness,  and  atmospheric 
vicissitudes ;  in  the  second  group,  so  far  as  ascertained,  inflamma- 
tion of  the  umbilicus  and  umbilical  vessels,  meningitis,  and, 
rarely,  injury  of  the  cerebro-spinal  axis  during  birth. 

The  lesions  resulting  from  tetanus  infantum  pertain  chiefly  to 
the  circulatory  system.  In  the  cases  examined  by  Prof.  Ceder- 
schjold,  of  Stockholm,  already  alluded  to,  the  meningeal  and 
cerebral  vessels,  and  those  of  the  spinal  cord,  the  cavities  of  the 
heart,  and  the  large  vessels  connected  with  the  heart,  were  dis- 
tended with  blood. 

Finckh  made  post-mortem  inspection  of  twenty  cases  in  the 
Stuttgart  Hospital,  the  bodies,  at  death,  having  been  placed  on 
their  faces,  in  order  to  prevent  any  deceptive  apjjearance  from 
the  gravitation  of  blood.  In  four  there  was  no  appreciable  altera- 
tion in  the  spinal  cord  or  its  membranes.  In  the  remaining  six- 
teen there  was  eff'usion  of  blood,  in  considerable  quantity,  the 
wnole  length  of  the  spinal  cord,  between  the  bony  walls  and  the 
dura  mater.  It  should  be  stated,  however,  that  there  was  spinal 
meningeal  inflammation  in  nine  of  the  sixteen,  though  the  extra- 
vasation did  not,  probably,  result  from  the  inflammation,  but  from 
the  tetanus.  The  blood  in  Finckh's  cases  was  very  dark,  some- 
times fluid,  at  other  times  coagulated.  In  one  case  there  was  no 
change  in  the  appearance  of  the  brain  or  its  membranes.  In  the 
remaining  nineteen,  more  or  less  extravasated  blood  was  found  on 
the  surface  of  the  brain,  or  in  its  interior.  The  substance  of  the 
brain  was  healthy,  as  also  its  membranes,  except  the  congestion. 
The  only  abnormal  appearance  observed  in  the  thoracic  and 
abdominal  viscera  was  strong  contraction  of  some  portion  of  the 
intestinal  tube  in  five  cases.  Dr.  West  says:  "The  most  frequent 
post-mortem  appearance  in  these  cases" — referring  to  tetanus 
infantum — "and  that  which  I  found  in  the  bodies  of  all  the  four 
children  whom  I  observed,  consists  of  eft'usion  of  blood,  either 
fluid  or  coagulated,  into  the  cellular  tissue  surrounding  the  theca 
of  the  cord.  Conjoined  with  this  there  is  generally  a  congested 
state  of  the  vessels  of  the  spinal  arachnoid,  and  sometimes  an  eflu- 


CAUSES.  397 

sion  of  blood  or  scrnni  into  its  cavity.  The  signs  of  congestion 
about  the  head  are  less  constant,  though  much  oftener  present  than 
absent,  and  sometimes  existing  in  an  extreme  degree;  while  in 
one  instance  I  found  not  merely  a  highly  congested  state  of  the 
cerebral  vessels,  but  also  an  effusion  of  blood,  in  considerable 
quantity,  between  the  skull  and  dura  mater,  and  also  a  slighter 
effusion  into  the  arachnoid  cavity."  Dr.  Weber,  of  Kiel,  also 
placed  infants  who  had  died  of  tetanus  on  their  faces,  and,  with- 
out exception,  found  injection  of  the  capillaries  of  the  cord  and 
spinal  meninges,  and  extravasation  of  blood.  M.  Matuszynski, 
according  to  Bouchut,  "has  observed  effusions  of  blood,  of  variable 
quantity,  in  the  cerebral  pia  mater,  in  the  ventricles,  and  in  the 
choroid  plexuses,  with  considerable  injection  of  the  membranes  of 
the  brain.  He  has  also  seen  serous  infiltration  beneath  the  arach- 
noid, and  serous  efllision  into  the  ventricles,  accompanied  by  a 
diminution  of  the  consistence  of  the  cerebral  substance."  In  two 
cases  examined  by  myself,  there  was  intense  injection  of  the  cere- 
bral meninges,  and  of  the  meninges  of  the  upper  part  of  the  spine, 
but  no  extravasation  was  noticed.  The  spinal  canal  was  not 
opened.  In  a  third  case,  in  which  the  spinal  canal  was  opened, 
there  was  extravasation  in  achlition  to  the  congestion ;  this  was 
especially  observed  along  the  spinal  theca. 

Dr.  II.  0.  Wooten  {N.  0.  Med.  and  Surg.  Journ.^  May,  1846)  states 
that  he  has  made  several  post-mortem  examinations,  and  has  found 
the  pathological  appearances  as  uniform  as  in  any  other  disease,  as 
follows :  "  Engorgement  of  the  substance  of  the  brain,  and  of  the 
meninges  lining  the  base  of  the  brain,  the  medulla  oblongata,  and 
spinal  marrow;  liver  congested." 

In  a  case  related  by  Dr.  Imlach  before  the  Edin.  Obst.  Soc, 
April  24, 1850,  the  upper  part  of  the  lungs  was  healthy,  the  poste- 
rior portion  congested,  and  containing  many  dark  points  ;  heart 
and  liver  healthy ;  small  intestines  of  a  light-brown  color;  stomach 
and  large  intestines  pale;  there  had  been  umbilical  hemorrhage. 

Romberg  states  that  he  found  in  a  child,  whose  death  occurred 
from  this  disease,  such  intense  congestion  of  the  veins  and  sinuses 
of  the  brain,  that  a  slight  touch,  and  the  removal  of  the  cranial 
bones,  produced  extravasation  of  the  partly  coagulated  and  partly 
fluid  blood.  Dr.  Scholler,  on  the  other  hand,  found  actual  extrava- 
sation of  blood  in  the  spinal  canal  in  only  one  case  in  eighteen. 

It  is  seen  from  the  above  observation,  that  tetanus  of  the  infant 
is  ordinarily  accompanied  by  great  passive  congestion,  which  is 


398  TETANUS    INFANTUM. 

especially  marked  in  the  cerebro-spinal  axis,  and  that  frequently 
extravasations  occur  from  the  distended  capillaries.  The  embar- 
rassment of  respiration  and  the  retarded  circulation  of  blood  con- 
sequent on  the  tetanic  rigidity  aitbrd  sufficient  explanation  of  this 
state  of  the  vessels. 

Symptoms. — In  many  cases  premonitory  symptoms  are  absent, 
or  are  so  slight  as  to  escape  notice.  Sometimes  there  is  a  degree 
of  fretfulness  previously,  but  no  more  than  is  often  observed  in 
those  who  continue  in  good  health.  The  fi.rst  symptom  which 
alarms  the  parents,  and  shows  the  grave  nature  of  the  commenc- 
ing disease,  is  inability  to  nurse,  or  evident  pain  and  hesitation 
in  nursing.  Commencing  with  rigidity  of  the  masseters,  the  dis- 
ease gradually  extends  to  the  other  voluntary  muscles,  and  in  the 
course  of  a  few  hours  the  muscles  of  the  limbs,  as  well  as  of  the 
trunk,  are  involved.  Persistent  muscular  contraction,  which  is 
the  pathognomonic  feature  of  infantile  tetanus,  is  developed  not 
fully  in  the  beginning,  but  by  degrees  in  each  affected  muscle, 
so  tliat  it  is  not  till  after  the  lapse  of  several  hours,  perhaps  even 
a  day,  that  the  greatest  amount  of  rigidity  is  attained.  Therefore, 
in  the  commencement  of  the  disease,  the  limbs  can  be  bent,  and 
the  jaws  pressed  open,  more  readily  than  at  a  subsequent  stage, 
though  with  manifest  pain  to  the  infant. 

During  the  period  of  maximum  rigidity,  the  jaws  are  fixed 
almost  immovably,  often  with  a  little  interspace  between  them, 
against  which  the  tongue  presses,  and  in  which  frothy  saliva  col- 
lects. The  head  is  thrown  backward  and  held  in  a  fixed  position 
by  the  stiffness  of  the  cervical  muscles.  The  forearms  are  flexed ; 
the  thumbs  are  thrown  across  the  palms  of  the  hands,  and  are 
firmly  clenched  by  the  fingers  ;  the  thighs  are  drawn  towards  the 
trunk ;  the  great  toes  are  adducted,  and  the  other  toes  flexed.  Oc- 
casionally opisthotonos  results  from  the  extreme  contraction  of  the 
dorsal  and  posterior  cervical  muscles.  The  infant  can  sometimes 
be  raised  without  any  yielding  of  the  muscles,  by  one  hand  under 
the  occiput  and  the  other  under  the  heels. 

The  rigidity  is  liable  to  variation  in  its  intensity,  even  after  the 
full  development  of  the  disease.  If  the  infant  is  quiet,  especially 
if  asleep,  the  muscles  are  partially  relaxed  to  such  an  extent,  some- 
times in  the  first  stages  of  the  complaint,  that  the  features  have  a 
placid  and  natural  expression,  though  only  for  a  short  time.  There 
are  frequent  exacerbations  in  the  muscular  contraction,  sometimes 
occurring  without  any  apparent  cause,  and  sometimes  produced  by 
anything  which  excites  or  disturbs  the  child.     Attempts  to  open 


SYMPTOMS.  899 

the  lips  or  jaws,  or  eyelids,  or  to  bend  the  limbs,  blowing  on  the 
face,  or  even  the  crawling  of  a  fly  upon  it,  occasions  the  paroxysm. 

During  the  paroxysm  the  eyelids  are  forcibly  compressed,  as  well 
as  the  lij)s,  which  are  either  drawn  in  or  are  pouting;  the  forehead 
and  cheeks  are  thrown  into  wrinkles,  and  the  physiognomy  is 
indicative  of  great  suffering.  The  unnatural  positions  of  the 
trunk  and  limbs,  which  result  IVom  the  muscular  contraction,  are 
increased  for  the  moment ;  the  head  is  more  forcibly  thrown  back, 
and  the  limbs  more  strongly  flexed.  The  muscular  movements 
which  occur  during  the  paroxysms  are  sometimes  described  as 
clonic  spasms.  There  is  indeed  occasionally  some  quivering  of  the 
limbs,  and  yet,  as  I  have  on  different  occasions  noticed,  so  far  from 
the  muscular  action  being  a  clonic  spasm,  it  possesses  a  tonic  cha- 
racter, which  is  at  times  intensified.  In  fatal  cases  the  paroxysms 
occur  more  and  more  frequently  until  the  period  of  collapse. 

The  crying  of  the  child  affected  by  tetanus  is  never  loud,  how- 
ever great  the  suffering.  It  is  variously  described  by  writers  as 
"whimpering"  or  "whining."  It  is  of  this  suppressed  character 
in  consequence  of  the  rigid  state  of  the  respiratory  muscles  and 
their  imperfect  movement. 

During  the  exacerbation  respiration  is  suspended,  or  so  imper- 
fect, and  the  circulation  so  retarded,  that  the  surface  becomes  of  a 
deep  red,  almost  livid,  color.  Sometimes  epistaxis  occurs,  affording 
partial  relief  to  the  congestion,  and  sometimes,  though  less  fre- 
quently, the  blood  forces  itself  from  the  congested  liver  along  the 
umbilical  vein,  and  escapes  from  the  umbilicus.  I  have  already 
alluded  to  the  occurrence  of  meningeal  apoplexy. 

The  frequency  of  the  pulse  and  respiration  varies  in  different 
cases,  and  at  different  stages  of  the  same  case.  They  are  often 
somewhat  accelerated,  but  at  other  times  are  natural,  or  are  even 
slower  than  in  health. 

"While  the  appetite  of  the  infant,  to  appearance,  is  not  dimin- 
ished, the  pain  which  it  experiences  in  nursing  is  such  that 
alimentation  is  necessarily  deficient.  It  can  be  fed  with  a  spoon 
for  a  time  after  it  ceases  to  take  food  in  the  natural  way,  but  arti- 
ficial feeding  soon  fails.  The  milk  placed  in  its  mouth  is  in  great 
part  pressed  back  through  the  violence  of  the  spasm  which  is 
induced  by  the  attempt  to  feed  it. 

In  consequence  of  imperfect  nutrition,  the  infant  rapidly  wastes 
away.  There  is  no  other  disease  except  the  diarrhoeal  affections 
in  which  emaciation  is  so  rapid.  In  a  case  related  by  Dr.  W.  B. 
Lindsay  in  the  N.  0.  Med.  Journ.,  Sept.  1846,  the  record  states 


400  TETANUS    INFANTUM. 

that  "the  infont  was  fat  three  clays  before,  but  was  now  emaci- 
ated." Romljerg,  who  saw  tetanus  infantum  in  European  hospi- 
tals, and  Dr.  Robert  H.  Chinn,  of  Texas  {N.  0.  Med.  and  Surg. 
Journ.^  Sept.  1854),  both  speak  of  the  rapid  emaciation.  The  trunk 
and  extremities  lose  their  fulness,  and  the  features  become  pinched. 
Several  observers  have  noticed  the  appearance  of  miliaria  in  this 
reduced  state  of  system,  especially  around  the  shoulders,  and  some- 
times a  decidedly  icteric  hue  appears  on  the  skin. 

The  condition  of  the  bowels  is  not  uniform.  They  may  be 
relaxed,  particularly  if  the  disease  is  due  to  some  irritation  in 
them ;  in  other  cases  the  stools  are  natural  or  constipated. 

It  is  often  difficult  to  ascertain  the  state  of  the  eyes,  since 
attempts  to  open  the  eyelids  bring  on  spasms  and  cause  firm 
compression  of  the  lids  against  each  other.  According  to  Sir 
Henry  Holland,  one  of  the  first  symptoms  w^hich  occurred  in  cases 
on  the  island  of  Heimacy,  was  strabismus,  with  rolling  of  the 
eyes.  But  this  statement  must  be  received  with  caution,  since 
these  cases  were  not  seen  by  any  physician,  and  the  information 
was  obtained  from  the  parents  and  priests.  If  true,  the  proximate 
cause  of  the  disease  in  Heimacy  would  seem  to  be  located  in  the 
cerebro-spinal  axis.  Contraction  of  the  pupils  commonlj^  occurs  in 
the  stage  of  collapse. 

Mode  of  Death. — Death  in  infantile  tetanus  may  occur  from 
apnoea  in  the  paroxysms,  from  extreme  congestion  of  the  cerebral 
vessels,  or  apoplexy ;  and,  lastly,  it  may  occur  from  exhaustion. 
The  last  mode  is,  probably,  the  most  frequent. 

Prognosis. — All  waiters  till  recently  agree  that  tetanus  of  the 
infant  rarely  terminates  favorably.  Cullen  attributes  the  ignorance 
of  physicians  in  regard  to  this  disease  to  the  fact  that  it  is  so  little 
amenable  to  treatment,  that  they  are  not  usually  summoned  to 
attend  those  affected  w^ith  it.  In  the  island  of  Heimacy,  of  one 
hundred  and  eighty-five  cases,  occurring  during  a  series  of  years 
about  the  commencement  of  the  present  century,  not  one  survived ; 
and  in  the  same  locality,  at  a  more  recent  period,  according  to  the 
report  of  Dr.  Schleisner  already  alluded  to,  sixty-four  per  cent, 
died.  Similar  statements  in  regard  to  the  mortality  of  tetanus 
infantum  are  given  by  physicians  in  the  southern  States.  Dr. 
H.  0.  Wooten,  of  Alabama,  says  {N.  0.  3Ied.  .louni.,  May,  1846)  that 
he  has  "  never  seen  a  decided  case  of  tetanus  nasccntium  that  did 
not  prove  fatal ;  .  .  .  and  that  it  is  very  generally  deemed  useless 
to  call  in  medical  aid  after  the  initiatory  symptoms  are  well 
declared."    Mr.  Maxw^ell,  speaking  in  reference  to  the  West  Indies, 


DURATION    IN    FATAL    CASES.  401 

says  {Jamaica  Phys.  Joiam.,  copied  into  the  London  Lancet,  April 
11th,  1885):  "From  observations  which  I  have  made  for  a  series 
of  years,  ...  I  found  tliat  the  depopulating  influence  of  trismus 
nascentium  was  not  less  than  twenty-five  per  cent.  It  scarcely  has 
a  parallel  within  the  bills  of  mortality."  Dr.  D.  B.  Nailer  (iV.  0. 
Med.  Joiirn.,  ]^ov.  1846)  says:  "About  two-thirds  of  the  deaths 
among  the  negro  children  are  from  this  disease,  and  so  uniformly 
fatal  is  it,  that  a  physician  is  never  sent  for." 

Yet  death  does  not  always  result.  Eight  of  the  forty  cases  in  my 
collection  recovered  ;  but  a  correct  opinion  cannot  be  formed  from 
this  of  the  actual  ratio  of  favorable  to  unfavorable  cases,  since 
favorable  cases  are  much  more  likely  to  be  published.  In  the 
history  of  these  eight  cases,  two  interesting  facts  are  noticed, 
which,  when  present,  may  serve  as  a  ground  for  hope  of  a  successful 
termination.  These  were,  the  age  at  which  the  disease  began,  and 
fluctuation  in  the  symptoms.  With  two  exceptions,  the  infants 
who  recovered  were  about  a  week  old  when  the  initiatory  symp- 
toms a]3peared,  and  there  were  fluctuations  in  the  gravity  of  the 
symptoms ;  whereas,  fatal  cases  ordinarily  grow  progressively  worse. 
Yet,  in  favorable  cases,  the  symptoms  are  never  so  severe  as  they 
become  in  a  few  hours  in  those  who  succumb. 

Duration  in  Fatal  Cases. — Of  eighteen  cases  observed  by  Finckh 
in  the  Stuttgart  Hospital,  fifteen  died  in  two  days,  two  in  five 
days,  and  one  in  seven  days.  During  the  epidemic  in  the  Stock- 
holm hospitals,  in  1834,  where  forty-two  cases  were  treated,  the 
disease  seldom  lasted  more  than  two  days.  Romberg  says:  "It 
generally  lasts  from  two  to  four  days,  but  its  duration  is  at  times 
limited  at  from  eight  to  twenty-four  hours,  and  occasionally, 
though  rarely,  it  extends  from  five  to  nine  days." 

In  thirty-one  fatal  cases  in  my  collection,  in  which  the  duration 
is  mentioned — 

One  lived 3  hours. 

Eleven  others  lived 1  day  or  less. 

Twelve  lived     .         . 3  days. 

Four        " 3     " 

Three      " 4    " 

Both  Underwood,  who  published  a  little  treatise  on  diseases  of 
children,  in  1789,  and  Dr.  Elsasser  at  a  more  recent  date,  record 
fatal  cases  which  were  unusually  protracted.  The  one  described 
by  Underwood  was  treated  in  the  British  Lying-in  Hospital,  and, 
although  all  the  others  treated  in  this  institution  died  by  the  third 
day,  this  lived  six  weeks ;  but  it  is  suggested  by  the  author,  that 
26 


402  TETANUS    INFANTUM. 

death  was  due  in  part  to  some  other  affection.     The  child  treated 
hy  Elsasser  lived  thirty-one  days. 

DuKATiox  IN  Favorable  Cases. — In  the  eight  favorable  cases  in 
my  collection,  the  duration  of  the  disease,  reckoned  from  the  time 
when  the  infant  ceased  nursing  till  it  began  again,  was  as  follows : 
In  one  case,  two  days ;  in  one,  a  few  days ;  in  one,  fourteen  days ; 
in  two,  fifteen  days ;  in  one,  twenty-eight  days ;  in  one,  twenty-one 
days;  and  in  the  remaining  case,  about  five  weeks. 

Diagnosis. — To  one  who  has  seen  this  disease  in  the  new-born, 
or  is  familiar  with  its  symptoms,  diagnosis  is  easy.  The  symptoms 
which  possess  diagnostic  value  are  more  manifest  and  reliable  than 
in  most  other  infantile  aflections.  Permanent  rigidity  of  the 
voluntary  muscles,  with  temporary  exacerbations,  such  as  have 
been  described  above,  which  are  induced  by  any  cause  which 
disturbs  the  infant — as  attempts  to  open  the  mouth  or  eyelids — is 
jjathognomonic. 

Preventive  Treatment. — While  tetanus  infantum,  if  fully 
developed,  is  ordinarily  fatal,  in  spite  of  any  remedial  measures 
heretofore  used,  there  is  no  doubt  of  the  efiicacy  and  value  of 
preventive  measures,  when  properly  employed.  This  was  shown 
by  the  great  reduction  in  mortality  in  the  Dublin  Lying-in  Hos- 
pital through  the  thorough  ventilation  introduced  by  Dr.  Clarke. 
Dr.  Meriwether,  of  Montgomery,  Ala.,  says  {Amer.  Journ.  of  3Ied. 
Sci.,  April,  1854):  "When  the  disease  appears  endemically  on  a 
plantation,  it  may  be  arrested  by  having  the  negro  houses  white- 
washed with  lime,  inside  and  out ;  by  raising  the  floors  above  the 
ground ;  by  removing  all  filth  from  under  and  about  the  houses ; 
by  particular  attention  to  cleanliness  in  the  bedding  and  clothes 
of  the  mother ;  and  in  the  dressing  of  the  child,  so  as  to  prevent 
any  of  the  matter  from  the  umbilicus  lying  long  in  contact  with 
the  skin."  Many  physicians,  especially  in  the  Southern  States, 
speak  confidently  of  care  in  dressing  the  cord,  and  attention  to  the 
umbilicus,  as  a  means  of  prevention.  In  the  N.  0.  Med.  and  Surg. 
Journ.,  July,  1853,  Dr.  Grafton  says  that  he  has  "never  known  the 
disease  to  occur  in  any  child  whose  navel  had  the  turpentine 
dressing."  lie  uses  turpentine  as  follows:  "At  the  first  time,  a 
few  drops  of  the  undiluted  turpentine  are  applied  immediately  to 
the  umbilicus  around  the  cord,  and  it  is  anointed  at  every  suc- 
ceeding dressing,  the  turpentine  being  diluted  one-half  or  two- 
thirds  with  olive  oil,  lard,  or  fresh  butter."  This  use  of  turpentine 
has  also  been  recommended  by  other  practitioners  in  the  warm 
regions. 


TREATMENT.  403 

Dr.  Jolm  Furloiigc,  of  St.  Jolin's,  Antigua,  believes  {Edin.  Med. 
and  Surg.  Journ.,  Jan.  1830)  that  no  case  would  occur  witli  the 
following  treatment :  "  The  cord,  when  divided,  should  be  wrapped 
in  clean  linen.  Every  night,  for  two  weeks,  one  or  two  drops  of 
tinct.  opii  and  spts.  vini,  equal  parts,  should  be  given,  and  castor 
oil,  with  a  little  magnesia,  every  morning.  The  child  must  be 
washed  in  tepid  water  every  morning,  and  the  funis  dressed."  If 
this  treatment  is  attended  by  the  success  which  is  claimed  for  it 
by  Dr.  Furlonge,  so  great  care  in  dressing  the  cord  is  certainly 
well  repaid  in  localities,  as  at  Antigua,  where  a  large  proportion 
of  the  infants  die  of  tetanus. 

Some  experienced  observers  go  so  far  as  to  assert  that  it  is 
possible  to  ward  off  tetanus  infantum  after  the  occurrence  of  pre- 
monitory symptoms.  Dr.  Dowell  says  {AMe?\  Journ.  of  the  Med. 
Sci.,  January,  1863):  "Some  with  slight  twitchings  of  the  muscles, 
have  recovered  without  any  trouble  by  being  put  into  a  mustard- 
bath,  washed  clean,  and  put  in  a  clean  and  well-ventilated  cabin." 

Treatment. — In  considering  the  effect  of  medicinal  agents  which 
have  been  employed  in  the  treatment  of  infantile  tetanus,  the 
great  difficulty  which  the  child  experiences  in  swallowing  should 
be  borne  in  mind.  Without  care,  a  considerable  part  of  the  dose 
is  lost  by  the  spasm  of  the  muscles  of  deglutition,  which  ordinarily 
occurs  when  the  spoon  is  placed  in  the  mouth,  so  that,  unless 
special  attention  is  given  to  this  matter,  it  is  uncertain  whether 
the  prescribed  dose  is  fully  administered. 

The  treatment  employed  by  different  physicians  has  been  very 
diverse.  Antiphlogistic  remedies  were  prescribed  by  Finckh,  but 
every  case  so  treated  was  fatal.  He  states  that  whenever  blood 
was  abstracted,  even  in  small  quantities,  the  symptoms  were 
aggravated.  The  same  result  has  followed  depletory  measures  in 
the  practice  of  other  physicians. 

The  internal  remedies  which  have  been  most  frequently  pre- 
scribed are  opiates  and  antispasmodics.  Furlonge,  in  a  favorable 
case,  gave  laudanum,  in  doses  of  one  drop  every  three  hours, 
alternately  with  two  grains  of  Dover's  powder.  Woodworth  also 
gave  one-drop  doses  of  laudanum ;  Eberle,  one-sixth  of  a  drop 
hourly.  The  opiate  has  generally  been  given  in  combination  with 
an  antispasmodic.  The  Dover's  powder,  given  every  three  hours 
by  Furlonge,  was  combined  with  five  grains  of  sulphate  of  zinc. 
The  hourly  doses  of  laudanum,  by  Eberle,  were  combined  with  six 
drops  of  tincture  of  assafoetida. 


404  TETANUS    INFANTUM. 

When  anresthetics  began  to  "be  employed  in  the  treatment  of 
diseases  it  was  believed  that  they  would  be  especially  useful  in 
cases  of  tetanus.  Accordingly  chloroform  has  been  used  in  tetanus 
in  the  infant,  with  the  effect  of  controlling  the  sj^asms  during  the 
time  of  its  use,  but  without  curing  the  disease.  In  Case  7  in  our 
first  table  it  was  employed  several  times,  but  apparently  without 
delaying  the  fatal  result.  The  editor  of  the  New  Orleans  Medical 
and  Surgical  Journal  states,  in  the  May  issue  of  that  periodical  for 
1853,  that  he  has  used  chloroform  in  tetanus  infantum,  with  the 
effect,  he  believes,  of  prolonging  life.  Anaesthetics  certainly  relieve 
the  suffering  of  the  infant,  and  on  this  account,  even  if  they  do 
not  prolong  life,  their  judicious  employment  seems  proper. 

The  remedy  which,  in  my  opinion,  is  far  preferable  to  all  others, 
is  hydrate  of  chloral.  Since  the  introduction  of  this  agent  into 
therapeutics,  it  has  been  employed  by  several  physicians  in  the 
treatment  of  this  disease  with  so  good  a  result  that  it  will  prob- 
ably supersede  all  other  medicines  for  this  purpose.  Dr.  Wider- 
hofer,  of  Vienna,  states  that  he  has  saved  six  out  of  ten  or  twelve 
by  the  use  of  chloral  {London  Lancet,  March  18,  1871).  He  pre- 
scribes it  in  doses  of  one  to  two  grains  by  the  mouth,  or,  if  there 
is  great  difficulty  in  swallowing,  two  to  four  grains  by  the  rectum. 
Dr.  F.  Auchenthales  relates  a  case  [Jahrb.f.  Kinderheil.,  'N.  S.  IV.) 
in  which  he  gave  even  six-grain  doses,  and  in  nine  days  the  disease 
had  entirely  disappeared.  I  have  employed  hydrate  of  chloral  in 
only  one  case  of  tetanus  infantum,  giving  it  in  half-grain  doses, 
every  two  hours,  except  when  there  was  profound  sleep.  The 
disease  was  fully  developed,  and  the  symptoms  severe  when  I 
was  called.  I  did  not  believe  that  the  infant  with  the  old 
remedies  would  live  more  than  two  days,  but  by  the  chloral  life 
was  prolonged  nearly  one  week.  Moreover,  by  the  use  of  chloral 
the  suffering  of  the  infant  is  greatly  diminished. 

The  administration  of  alcoholic  stimulants  is  required  at  short 
intervals  on  account  of  the  rapid  emaciation  and  great  prostration. 

Local  treatment  directed  to  the  umbilicus  in  those  cases  in  which 
there  is  evidence  of  inflammation  of  the  umbilicus  or  umbilical 
vessels  should  not  be  neglected.  Vesication  of  the  umbilicus,  and 
the  application  of  poultices  to  it,  have  been  followed  by  unques- 
tionable benefit,  if  we  may  believe  the  statement  of  some  physicians 
who  have  made  use  of  these  measures.  Dr.  Merriwether,  of 
Alabama,  says,  if  there  is  no  improvement  from  the  medicine 
which  he  orders,  he  applies  a  blister,  larger  than  a  dollar,  to  the 


INTERNAL    CONVULSIONS.  405 

iinihiliciis,  and  with  this  trcatmoMt  the  child  generally  improves; 
a  remarkable  statement,  since  so  few  improve  at  all. 

A  warm  foot-bath  repeated  at  intervals  of  a  few  hours,  and 
stimulating  embrocations  along  the  spine,  are  proper  adjuvants  to 
the  treatment. 


CHAPTER   XIII. 
INTERNAL  CONVULSIONS. 

Young  children  are  liable  to  temporary  suspension  of  respiration, 
induced  by  violent  emotions,  especially  by  anger.  In  the  midst  of 
their  excitement,  while  they  are  crying  or  screaming,  their  breath 
is  suddenly  held,  as  if  from  tonic  spasm  of  the  respiratory  muscles. 
In  a  few  seconds  respiration  returns,  and  is  natural.  There  is  no 
stridulous  inspiration  or  other  unusual  sound,  and  there  is  no 
apparent  ill  effect,  unless  occasionally  a  degree  of  languor.  Ex- 
ternal convulsions,  which  seem  to  be  threatening,  seldom  occur, 
and  when  they  do,  are  ordinarily  mild.  Some  writers  consider 
dentition  the  predisposing  cause  of  this  arrest  of  respiration,  by 
inducino-  a  sensitive  state  of  the  nervous  svstem.  Such  an  effect 
of  dentition  is  possible,  but  certainly  many  infants  are  affected  in 
this  manner  before  the  as-e  of  dentition. 

A  much  more  serious  state,  and  one  which  is  recognized  as  a 
true  disease,  is  that  variously  designated  by  writers  as  internal 
convulsions,  spasm  of  the  glottis,  child-crowing,  laryngismus 
stridulus,  etc.  Manifest  difficulties  attend  the  investigation  of  the 
pathological  state  in  this  disease.  There  can  be  little  doubt  that 
it  is  not  precisely  the  same  in  all  cases.  That  there  is,  during  the 
paroxysms,  tonic  or  clonic  spasm  of  more  or  fewer  of  the  respiratory 
muscles  is  inferred  not  only  from  the  symptoms  pertaining  to  the 
respiratory  apparatus,  but  from  the  fact  that  in  severe  cases  there 
are  often  spasms  of  the  external  muscles,  as  those  of  the  limbs  and 
face.  Usually,  also,  the  movements  of  the  eyeballs  indicate 
spasmodic  contractions  of  the  motor  muscles  of  the  eyes.  The 
occurrence  of  these  contractions  in  parts  that  are  visible  justifies 
the  belief  that  they  occur  in  other  parts  which  are  concealed  from 
view,  especially  as  the  characteristic  symptoms  cannot  be  readily 
explained  except  on  this  supposition.  Trousseau  says:  "Internal 
convulsions  consist,  then,  principally  in  a  spasm  of  the  diaphragm 


406  INTERNAL    CONVULSIONS. 

and  of  the  respiratory  muscles  of  the  abdomen  and  chest ;  hut  it 
occurs,  also,  that  the  muscles  pertaining  to  the  larynx  are  affected 
with  spasm  at  the  same  time  with  these."  Rilliet  and  Barthez 
conclude  from  the  symptoms  that  the  "  heart  is  not  always  a 
stranger  to  this  internal  convulsion,  which,  perhaps,  prolongs  itself 
even  to  the  intestines."  The  muscles  of  the  pharynx  appear  to  be 
involved,  in  some  cases,  as  Avell  as  those  of  respiration,  rendering 
deglutition  difficult.  In  one  form  of  internal  convulsions,  namely, 
that  which  is  jDrincipally  referred  to  by  writers,  there  is  not 
complete  arrest  of  respiration,  but  the  inspirations,  during  the 
paroxysm,  are  difficult  and  are  attended  by  a  stridulous  noise. 
Again,  the  respiration  may  cease  entirely,  but  when  it  commences 
it  is  stridulous,  and  difficult  for  a  few  inspirations.  In  still 
another  form  of  the  disease  respiration  ceases,  but  there  is  no 
symptom  or  sign  indicative  of  glottic  spasm  or  of  an  obstacle  to 
the  ingress  of  air ;  the  inspirations  which  succeed  the  paroxysm 
are  easy  and  noiseless.  It  has  been  suggested  that,  in  these  cases, 
there  is  paralysis  rather  than  spasmodic  contraction  of  the  respi- 
ratory muscles,  but  the  symptoms  may  be  explained  in  accordance 
with  the  commonly  accepted  opinion,  namely,  that  there  is  spasm 
of  the  diaphragm  and,  perhaps,  some  of  the  muscles  of  the  chest 
and  abdomen,  while  the  laryngeal  muscles  are  not  affected.  M. 
Ilerard,  indeed,  who  has  written  one  of  the  best  monographs  on 
internal  convulsions,  describes  three  forms  of  the  disease,  according 
to  the  supposed  location  of  the  spasm,  namely,  laryngeal,  dia- 
phragmatic, and  another,  which  consists  of  a  blending  of  the  two. 

Internal  convulsions  are  not  frequent  in  this  country  ;  they  are 
rare  in  France,  more  frequent  in  Germany,  and  quite  common  in 
England.  They  occur,  with  few  exceptions,  before  the  age  of  two 
years.  Dr.  West  observed  thirty-one  cases  under  the  age  of  two 
years,  and  only  six  above  that  age. 

Causes. — The  causes  of  internal  convulsions  are  not  fully  ascer- 
tained. Most  observers  have  remarked  the  relative  frequencj^  of 
the  disease  during  the  period  of  dentition,  and  it  is  probable  that 
dental  evolution  does  operate  as  a  cause,  by  rendering  the  nervous 
system  more  impressible. 

Spasm  of  the  glottis  has  been  attributed  to  enlargement  of  the 
thymus  gland,  and  also  to  enlargement  of  the  cervical  and  bron- 
chial glands.  It  is  presumed  that  this  effect  is  due  to  the  pressure 
of  these  glands  on  the  par  vagum,  or  the  recurrent  laryngeal  nerve. 
It  is  certain,  however,  that  there  is  no  such  enlargement  of  the 
thymus  gland  which  could  possibly  produce  glottic  spasm,  or  any 


CAUSES.  407 

other  form  of  internal  convulsions  at  the  age  at  which  these  con- 
vulsions commonly  occur.  Tliis  gland  is  largest  in  the  new-born, 
and  having  no  function  after  birth,  it  gradually  becomes  atrophied. 
If  enlarged  thymus  could  produce  glottic  spasm,  it  would  certainly 
occur  most  frequently  in  the  new-born.  Abnormal  development 
of  the  thymus  gland  was  the  only  assignable  cause  of  atelectasis  in 
two  infants  who  died  soon  afterbirth,  but  I  have  never  seen  a  case 
in  which  a  convulsive  attack  was  referable  to  this  cause.  M.  He- 
rard  examined  the  thymus  gland  in  six  children  who  died  of  inter- 
nal convulsions,  and  in  sixty  who  died  of  other  affections,  and  was 
not  able  to  discover  in  its  condition  any  causative  relation  to  this 
disease.  Indeed,  cases  have  been  reported  in  which  the  thymus 
had  undergone  more  than  its  usual  atrophy  at  the  time  when  the 
convulsions  occurred  (Ilasse).  Enlargements  of  the  lymphatic 
glands  in  the  vicinity  of  the  pneumogastric  or  recurrent  laryngeal 
nerve  may  possibly  give  rise  to  glottic  spasm,  but  this  is  doubtless 
an  infrequent  cause,  if  it  be  a  cause  at  all,  since  these  glands  are 
often  greatly  enlarged  in  strumous  and  tubercular  diseases  without 
such  a  result.  According  to  Dr.  Jacobi  {N.  Y.  Journ.  of  Med.,  Jan. 
1860):  "In  some  cases  described  by  Dr.  Friedleben,  a  congenital 
hypertrophy  of  the  thyroid  gland  has  probably  been  the  cause  of 
laryngismus.  The  patients  were  new-born  infants  of  normal  de- 
velopment, and  born  by  normal  labors.  There  were  no  constitu- 
tional causes  of  the  disease,  but  a  remarkable  vascular  swelling 
of  the  thyroid  gland.  Whenever  the  swelling  increased,  the  veins 
of  the  face  and  head  increased  in  size  also,  the  face  grew  livid,  and 
the  extremities  and  spinal  column  exhibited  slight  tonic  convul- 
sions. The  recurrent  nerves  were  entirely  surrounded  by  the 
glandular  tissue,  their  neurilemma  looked  unusually  red,  and  their 
functions  were  probably  injured  during  the  occasional  swelling 
taking  place  during  lifetime." 

The  cause  is  occasionally  located  in  the  cerebro-spinal  ^axis. 
Thus  Dr.  Coley  relates  a  case  in  which  an  exostosis  arising  from 
the  internal  surface  of  the  occipital  bone  pressed  upon  the  cere- 
bellum, while  nothing  abnormal  was  discovered  in  other  organs. 
There  are  also  striking  examples  in  which  the  cause  was  located 
in  the  spinal  cord.  Thus  Marshall  Hall  relates  the  following  case 
communicated  to  him.  A  child  with  spina  bifida  was  attacked 
with  croup-like  convulsions,  whenever  it  lay  so  as  to  press  on  the 
tumor. 

In  some  patients  there  is  evidently  an  hereditary  predisposition 
to  this  disease  ;  those  affected  belonging  to  families  in  which  there 


408  INTERNAL    CONVULSIONS. 

is  a  tendency  to  convulsive  affections.  Thus  Toogood  relates  that 
five  infants  of  the  same  family  were  aft'ected  with  spasm  of  the 
glottis  ;  and  Reid  relates,  on  the  authority  of  Powel,  that  of  thir- 
teen infants  of  the  same  parents  only  one  escaped  internal  convul- 
sions. 

The  common  predisposing  cause  is  an  excitable  state  of  the  ner- 
vous system,  often  associated  with  impaired  general  health.  Hence 
the  disease  is  more  prevalent  in  cities,  where  anti-hygienic  condi- 
tions abound,  than  in  the  country.  Hence,  too,  the  frequent  im- 
provement when  the  patient  is  removed  to  the  pure  and  bracing 
air  of  the  country.  The  use  of  insufficient  food,  or  food  of  a  bad 
quality,  must  for  the  same  reason  be  considered  a  cause,  as  it  leads 
to  impoverishment  of  the  blood,  and  renders  the  nervous  system 
more  impressible.  Facts  mentioned  by  Reid  and  others  show  con- 
clusively the  influence  of  premature  weaning,  and  of  indigestible 
or  otherwise  improper  aliment,  in  the  production  of  this  disease. 

The  causes  enumerated  above  are  for  the  most  part  predisposing ; 
occasionally  they  are  the  only  apparent  causes,  since  this  disease 
sometimes  occurs  when  the  child  is  perfectly  tranquil,  even  in  the 
midst  of  quiet  sleep,  or  when  it  is  at  rest  in  its  mother's  arms.  In 
other  cases,  and  more  frequently,  there  is  an  exciting  cause,  often 
trivial.  Anything  that  requires  exertion  on  the  part  of  the  infant, 
or  that  excites  strong  emotions,  may  be  a  direct  cause,  as  anger, 
or  any  of  the  violent  passions  ;  so  may  even  coughing,  or,  in  rare 
instances,  attempts  to  swallow.  One  author  has  known  it  to  occur 
from  excitement  produced  by  examining  the  throat  with  a  spoon. 
In  a  case  in  my  practice,  hereafter  related,  it  occurred  whenever 
the  infant  cried  violently.  It  appears  from  the  above  facts  that 
the  etiology  of  internal  convulsions  is  very  similar  to  that  of  eclamp- 
sia. The  same  spasmodic  muscular  contraction  may  occur  from  a 
variety  of  causes. 

Anatomical  Characters. — While,  therefore,  structural  changes 
in  various  parts  of  the  system  may  give  rise  to  internal  convulsions, 
this  disease,  so  far  as  ascertained,  presents  no  anatomical  charac- 
ters, and  must  consequently  be  considered  one  of  the  neuroses.  The 
lesions  of  the  respiratory  apparatus,  observed  at  pott-mortem  exami- 
nations, are  either  due  to  the  convulsions  or  are  coincidences.  Em- 
physema has  sometimes  been  observed  as  a  result,  it  is  believed,  of 
the  spasmodic  and  irregular  respiration.  It  was  present  in  all  of 
Herard's  cases,  and  Rilliet  and  Barthez  consider  it  common  in  those 
who  die  of  this  affection,  although  they  did  not  observe  it  in  any 
of  their  cases.     Slight  emphysema  occurring  in  the  upper  lobes  is, 


SYMPTOMS.  409 

however,  a  common  lesion  in  feeble  infants,  whatever  the  disease 
of  which  they  die.  Therefore  its  occurrence  in  internal  convul- 
sions is  probably  more  due  to  molecular  change  in  the  lungs,  since 
these  patients  are  cachectic,  than  to  the  irregular  breathing,  which 
is  only  momentary. 

In  fatal  cases  of  internal  convulsions  the  blood  is  darker  than 
usual,  from  an  excess  of  carbonic  acid ;  the  cavities  of  the  heart 
and  large  vessels  are  sometimes  engorged  with  blood,  but  in  other 
cases  they  contain  no  more  than  the  normal  amount.  More  or 
less  passive  congestion  occurs  in  the  internal  organs ;  and  congestion 
of  the  cerebral  vessels  is  sometimes  such  that  transudation  of  serum 
occurs. 

Symptoms. — I  have  said  that  the  symptoms  vary  according  to 
the  seat  and  function  of  the  muscles  which  are  affected.  There  is 
generally  previous  ill  health.  The  child  is  drooping,  and  is  some- 
times restless  for  days  before  the  disease  appears.  Finally,  if  the 
muscles  of  the  glottis  become  affected,  the  peculiar  crowing  sound 
is  heard  now  and  then  during  inspiration.  It  is  observed  espe- 
cially when  the  child  is  crying  or  is  agitated.  It  may  be  loud 
and  well  defined  from  the  first,  but  in  most  patients  it  comes  on 
gradually,  so  that  several  days  elapse  before  its  full  stridulous 
character  is  developed.  The  attacks  are  more  frequent  and  severe 
at  night,  in  or  after  the  first  sleep,  than  in  daytime. 

Under  favorable  hygienic  conditions,  the  disease  may  pass  oS 
without  becoming  more  serious.  In  other  cases  the  paroxysms 
gradually  increase  in  frequency  and  severity.  The  dyspnoea  in 
the  attack  is  such  that  the  features  are  livid,  the  head  forcibly 
retracted,  and  death  seems  imminent  from  apnoea.  In  these  severe 
paroxysms  respiration  often  ceases  entirely  for  a  moment.  When 
the  spasm  ends,  a  deep  stridulous  inspiration  occurs,  after  which 
the  breathing  is  natural.  It  has  been  stated  that  internal  convul- 
sions are  often  associated  with  those,  usually  tonic,  but  sometimes 
clonic,  of  the  external  muscles.  In  the  tonic  form,  the  thumbs  are 
flexed  across  the  palms  of  the  hands,  and  sometimes  are  grasped 
by  the  fingers;  the  great  toes  are  adducted,  and  the  other  toes 
flexed.  In  severe  cases,  the  hands,  forearms,  feet,  and  legs  are  also 
somewhat  flexed  and  rigid.  At  first,  the  contraction  of  the  external 
muscles  is  temporary,  either  corresponding  with  the  internal  spasm, 
or  it  is  most  intense  at  the  time  of  the  spasm,  though  commencing 
sooner  and  subsiding  later.  After  a  while,  however,  if  the  dis- 
ease continues,  the  external  contraction  becomes  more  persistent. 
In  severe  cases,  nearly  every  inspiration  is  accompanied  by  the 


410  INTERNAL    CONVULSIONS. 

wheezing  sound,  and  the  paroxysms  of  dyspnoea  are  excited  by 
trifling  causes.  Anything  that  suddenly  disturbs  the  mind  or 
body  may  bring  on  the  attack,  as  anger,  the  impression  of  cold, 
or  currents  of  air.  Dr.  West  calls  attention  to  the  fact  that  an 
anasarcous  condition  is  sometimes  present,  accompanied  by  albu- 
minuria. 

If  the  convulsions  affect  other  muscles,  as  the  diaphragm  or  the 
pectoral  and  abdominal  muscles,  which  are  concerned  in  the 
respiratory  function,  while  those  of  the  larynx  escape,  respiration 
is  irregular,  or  even  suspended  for  a  moment,  but  the  stridulous 
laryngeal  sound  is  absent,  as  there  is  no  obstacle  in  the  larynx  to 
the  entrance  of  air.  In  this  form  of  the  disease,  the  infra-mam- 
mary region  ma}'  be  strongly  retracted  during  the  paroxysm 
from  tonic  conti-action  of  the  diaphragm.  In  severe  paroxysms, 
whether  the  spasm  be  laryngeal  or  diaphragmatic,  consciousness 
is  nearly  or  quite  lost,  the  features  may  be  pallid,  or,  if  respiration 
be  suspended,  may  be  more  or  less  livid.  There  is  no  fever  in 
simple  cases.  In  the  paroxysm  there  is  often  relaxation  of  the 
sphincters  of  the  bowels  and  bladder,  with  involuntary  evacuations. 

The  duration  of  the  paroxysm  may  be  a  quarter,  a  half,  or  even 
a  whole  minute.  Total  suspension  of  respiration  for  even  half  a 
minute  involves  danger.  In  mild  cases  there  may  be  but  few 
paroxysms,  and  they  slight.  In  other  instances  they  occur  in  a 
severe  form,  almost  daily  for  several  weeks  or  even  months.  In 
the  following  case  the  muscles  of  the  larynx  were  apparently  not 
involved.  Tlie  patient  was  scrofulous,  and  has  since  had  scrofulous 
periostitis,  with  necrosis  and  exfoliation  of  the  surface  of  the  tibia. 
At  the  time  of  the  internal  convulsions  there  was  also  a  scorbutic 
or  hemorrhagic  cachexia. 

Case. — On  the  28tli  of  August,  1858,  a  German  female  infant,  four- 
teen months  old,  nursing,  and  having  eight  teeth,  was  suddenly  seized 
with  clonic  convulsions.  Uniformly  delicate  and  pale,  she  had  been  in 
her  usual  health  till  the  age  of  twelve  months,  when  she  had  a  single 
convulsive  attack,  and  from  that  date  had'remained  well  till  August  27, 
when,  witiiout  any  premonitory  symptom,  she  had  a  stool  consisting  of 
almost  pure  blood,  black  and  offensive.  Ou  the  morning  of  the  28th  a 
similar  evacuation  occurred,  and  another  in  the  afternoon  immediately 
preceding  the  convulsion.  Pulse  128,  after  the  convulsion;  surface 
cool  and  pallid;  flesh  soft,  but  no  emaciation.  Turpentine  was  prescribed 
in  two-drop  doses  every  two  hours,  and  laudanum  in  one  and  ahalf  drop 
doses  repeated  sufficiently  to  insure  quietude. 

On  the  29th  the  pulse  was  152.  At  1  P.M.  she  had  a  general  convulsion, 
lasting  about  five  minutes;  in  the  evening  she  had  an  evacuation 
similar  to  those  passed  on  the  preceding  day.  The  record  for  August 
30  states:  "Pulse  from  150  to  160;  up  to  this  time  has  been  playful. 


DIAGNOSIS  —  PROGNOSIS.  411 

but  is  now  drows_y,  and,  when  disturbed,  fretful;  manifests  no  desire 
for  solid  food,  as  before  her  sickness,  but  still  nurses;  has  taken  up 
to  this  tiuie  tliirty-two  drops  of  turpentine.  "When  she  cries  or  frets, 
she  has  a  spasmodic  attack."  This  was  the  commencement  of  internal 
convulsions,  with  which  this  child  was  affected  for  several  months.  An 
opportunit}^  was  afforded  of  observing  their  character,  for  her  excite- 
ment, when  she  was  examined,  was  usually  sufficient  to  produce  them. 
After  a  succession  of  short  expirations,  respiration  ceased ;  for  a 
moment  she  was  apparently  insensible;  eyes  closed;  face  pale;  no 
frothing  at  the  mouth.  The  return  of  consciousness  and  respiration  was 
without  any  laryngeal  rale ;  and  after  the  attack  she  seemed  as  well  as 
before.  No  external  convulsion  and  no  evacuation  of  blood  occurred 
after  August  31. 

There  was  gradual  improvement  in  her  health,  but  she  continued 
for  many  months  pallid  and  irritable,  and  subject  to  attacks  of  internal 
convulsions.  On  the  11th  of  April,  1859,  when  twenty-two  months 
old,  she  had  another  attack  of  general  convulsions.  The  record  made 
on  that  da}^  is:  "Has  had  internal  convulsions  (one  or  more  paroxj'sms) 
almost  every  day  since  last  August,  brought  on  usually  by  cr3'^ing  when 
she  is  corrected  in  any  way,  or  her  wishes  are  refused."  Again,  on  Dec. 
1, 1859,  it  is  stated  :  "  lias  grown  considerably  since  the  last  record,  and 
appears  to  have  recovered,  except  that  at  long  intervals  the  spasms  still 
occur."  She  took  a  preparation  of  iron,  but  her  recovery  seemed  to  be 
due  more  to  the  growth  and  development  of  the  body,  and  to  hygienic 
than  therapeutic  measures. 

The  general  healtli  in  internal  convulsions  is  more  or  less  im- 
paired, except  in  mild,  forms  of  the  disease,  in  which  the  convul- 
sive attacks  soon  cease.  Pallor,  or  a  sickly  and  cachectic  aspect, 
irregular,  usually  constipated  bowels,  poor  appetite,  and  morose- 
ness  or  irritability  of  temper,  are  common  symptoms  of  severe  and 
protracted  cases. 

Diagnosis. — This  disease  is  easily  diagnosticated,  unless  when 
its  symptoms  are  masked  by  those  of  external  convulsions  ;  it  may 
then  escape  notice.  Spasm  of  the  glottis  may  be  mistaken  for 
spasmodic  laryngitis,  and  vice  versa.  In  some  of  the  published 
cases  this  mistake  appears  to  have  been  made.  Spasmodic  laryngitis 
is,  however,  so  difterent  not  only  in  its  nature,  but  in  its  clinical 
history,  that  a  diflerential  diagnosis  is  not  difficult.  It  is  an 
inflammatory  disease,  and  is  attended  with  febrile  reaction  and  a 
sonorous  cough ;  it  commences  at  night  after  the  first  sleep,  and 
from  exposure  to  cold — particulars  in  regard  to  which  it  contrasts 
with  true  spasm  of  the  glottis. 

Prognosis.  Modes  op  Death. — Statistics  show  great  mortality 
in  this  disease.  Dr.  Reid,  in  a  monograph  on  "Infantile  Laryn- 
gismus," states  that  of  289  cases  which  he  collated,  115  died. 
Rilliet  and  Barthez  met  with  one  favorable  case  in  nine  unfavorable ; 
and  Ilerard,  one  in  seven.     If  the  paroxysms  are  mild,  infrequent, 


412  INTERNAL    CONVULSIONS. 

and  dependent  on  a  cause  which  can  be  easily  removed,  recovery- 
is  probable  with  proper  treatment.  The  cause  may,  however,  be 
such,  even  when  the  spasm  is  mild,  that  the  case  is  necessarily 
unfavorable;  as  when  it  is  due  to  disease  of  the  cerebro-spinal  axis. 
We  should  not,  however,  in  any  case  consider  the  patient  entirely 
safe,  since  grave  symptoms  may  suddenly  arise,  so  as  to  change 
entirely  the  prognosis.  Long  and  severe  paroxysms,  with  lividity 
of  the  face,  and  symptoms  of  suffocation,  indicate  an  unfavorable 
result.  The  same  should  be  predicted  also  if  the  infant  gradually 
waste  away,  losing  appetite  and  strength,  especially  if  the  face  is 
pale  and  the  pulse  feeble. 

There  are  three  modes  of  death  in  internal  convulsions.  The  first 
is  apnoea.  The  infant  dies  suffocated  in  the  attack.  Respiration 
is  first  arrested,  and  then  the  pulse  ceases,  and  at  the  autopsy  the 
lungs  and  the  cavities  of  the  heart  are  found  engorged  with  dark 
blood.  Death  may  also  occur  from  the  state  of  the  brain.  In  such 
cases,  passive  congestion  of  the  brain  occurs  from  obstruction  to  the 
return  of  blood  from  this  organ  to  the  heart  and  lungs ;  and  if  this 
congestion  is  not  soon  relieved,  serous  effusion  also  occurs.  Death 
results  from  the  congestion,  and  consequent  oedema  or  dropsy. 

Tlie  third  mode  of  death  is  from  exhaustion.  Repeated  and 
severe  attacks  undermine  the  constitution ;  the  infant  grows  pale 
and  thin  gradually,  and  dies  of  inanition,  or  of  some  disease  which 
this  state  induces. 

Treatment. — The  treatment  of  internal  convulsions  has  varied 
according  to  the  theories  which  physicians  have  held  in  reference 
to  its  cause.  Glandular  enlargement  is  no  longer  regarded  as  a 
common  cause,  and  therefore  treatment  directed  to  its  removal  is 
less  frequently  employed  than  formerly.  The  causes  of  internal 
convulsions  are  in  part  very  similar  to  those  of  eclampsia,  and  the 
remedies  employed  in  the  one  affection  are,  in  a  measure,  appro- 
priate in  the  other.  That  dentition  is  sometimes  a  cause,  is  usually 
admitted;  and  two  cases,  one  of  which  occurred  in  my  practice, 
and  the  other  was  reported  to  me,  clearlj^  show  the  truth  of  this 
belief.  The  effect  of  dentition  is  especially  observed  in  weakly 
infants,  when  several  dental  follicles  are  undergoing  active  evolu- 
tion. Thus,  in  one  of  the  cases  to  which  I  refer,  five  teeth  pierced 
the  gums  in  the  course  of  two  weeks ;  after  which  no  convulsive 
attack  occurred.  If,  therefore,  the  gums  are  swollen,  scarification 
is  proper. 

In  all  cases  of  internal  convulsions  a  careful  examination  should 
be  made,  in  order  to  detect  any  appreciable  cause  of  nervous  exci- 


TREATMENT.  413 

tation.  Tlic  condition  of  the  digestive  ore;ans  should  be  aBcertaincd, 
and  evacuants  or  other  remedies  prescribed  if  there  is  evidence  of 
their  derangement. 

Sometimes  the  alimentation  of  the  infant  is  in  fault.  It  is, 
perhaps,  bottle-fed,  and  the  stools  have  an  unhealthy  appearance. 
Attention  should  be  given  to  the  preparation  of  its  food  and  the 
times  of  its  feeding;  or,  if  it  nurse,  the  mother  or  wet-nurse  who 
suckles"  it  should  have  j)lain  but  nutritious  diet,  live  with  regu- 
larity, and  give  the  breast  to  the  infant  at  regular  intervals.  If 
there  is  a  torpid  state  of  the  bowels,  Dr.  Meigs  recommends 
"castor  oil  and  aromatic  syrup  of  rhubarb  rubbed  up  together, 
three  parts  of  the  former  and  five  of  the  latter."  A  simple  enema 
answers  well  in  such  cases,  and,  in  debilitated  infants,  this  is 
preferable  to  medicine  administered  by  the  mouth.  If  there  be 
diarrhoea,  and  it  persist  after  the  requisite  changes  are  made  in 
regard  to  the  diet,  remedies  calculated  to  relieve  it,  and  which  are 
detailed  elsewhere,  should  be  employed.  Marshall  Hall  states 
that  he  has  ordinarily  succeeded  in  curing  the  disease  by  attending 
to  the  condition  of  the  gums  and  digestive  organs. 

In  pallid  and  cachectic  infants,  tonics  are  required.  The  elixir 
of  Calisaya  bark  in  half-teaspoonful  doses,  three  or  four  times 
daily,  to  an  infant  of  one  year,  is  an  eligible  preparation.  The 
compound  tincture  of  bark,  or  of  gentian,  or  the  two  mixed,  may 
be  given  instead  of  the  Calisaya  bark.  The  preparations  of  iron 
are  sometimes  to  be  preferred.  The  best  of  these  are  the  sj-rup 
of  iodide  of  iron,  tincture  of  iron,  or  the  wine  of  iron.  To  an 
infant  of  one  year  the  syrup  may  be  given  in  doses  of  four  drops, 
the  tincture  of  two  drops,  and  the  wine  in  doses  of  one  teaspoonful, 
three  times  daily.  If  the  child  is  old  enough,  it  may  take  iron  in 
lozenges,  as  those  of  chocolate  and  iron. 

Antispasmodics,  as  assafoetida,  valerian,  and  oxide  of  zinc,  are 
often  prescribed  in  this  disease,  but  they  are  less  efficacious  than 
the  general  tonic  measures  which  I  have  indicated.  The  salutary 
effect  of  bromide  of  potassium  in  eclampsia,  and  certain  epilepti- 
formx  attacks,  certainly  justifies  the  trial  of  this  agent  in  internal 
convulsions,  if  they  persist  after  the  employment  of  invigorating 
measures. 

Hygienic  measures  are  of  the  utmost  importance.  The  infant 
should  reside  in  dry  and  airy  apartments,  and  should  be  kept  much 
of  the  time  through  the  day  in  the  open  air.  Remarkable  success 
sometimes  attends  this  simple  expedient,  when  medicines  have 
entirely  failed.      In  the  London  Med.  Gazette,  Jan.  14,  1865,  Mr. 


414  INTERNAL    CONVULSIONS. 

Hobertson,  of  Manchester,  relates  five  severe  cases  in  which  this 
disease  was  cured  by  exposure  of  the  infants  several  hours  daily 
to  a  cool  atmosphere.  These  cases  were  treated  in  the  winter 
months,  and  were  kept  out-door,  even  during  strong  winds.  Mr. 
Robertson  has  records  of  forty  cases,  all  occurring  betw^een  Decem- 
ber and  April,  while  he  has  seen  no  case  in  the  summer  months. 
As  the  result  of  such  extensive  experience,  this  writer  recommends 
"the  free  exposure  of  the  infant  out  of  doors,  for  many  hours 
daily,  to  a  dry,  cold  atmosphere,  and  if  the  air  be  dry,  the  colder 
the  better."  Dr.  Marshall  Hall's  experience  was  similar.  Says 
he :  "  The  curative  influence  of  change  of  air,  and  especially  of  the 
sea-breezes,  is  not  less  marked  in  this  aflection  than  in  hooping- 
cough."  Mr.  Robertson  recommends  also,  as  part  of  the  tonic 
treatment,  "free  sponging  of  the  body  every  morning  with  cold 
w^ater."  In  February,  1867,  I  attended  a  nursing  infant,  five 
months  old,  wath  internal  convulsions,  the  paroxysms  being 
attended  wdth  lividity  of  the  face,  and,  at  times,  tonic  convulsions 
of  the  limbs.  Among  the  remedies  employed  was  bromide  of 
potassium,  but  more  benefit  obviously  accrued  from  keeping  the 
infant  much  of  the  time  in  the  open  air,  than  from  the  medicines 
employed.     The  disease  passed  off  in  six  or  eight  weeks. 

Unless  the  cause  is  of  such  nature  that  it  cannot  be  removed, 
the  above  hygienic  and  therapeutic  measures  will,  in  a  large  pro- 
portion of  cases,  be  followed  by  a  satisfactory  result. 

The  mother  or  nurse  may  abridge  the  paroxysm  by  raising  the 
infant,  blowing  upon  it,  sprinkling  water  in  the  face,  or  gently 
stroking  it.  Dr.  Hall  recommends  tickling  the  nostrils  with  a 
feather,  to  produce  respiration,  or  the  fauces,  to  occasion  vomiting, 
and  thereby  interrupt  the  paroxysm.  Anything  which  produces 
a  sudden  and  j)rofound  eflect  upon  the  system  may  abridge  the 
attack.  This  was  effected  in  one  case,  in  the  practice  of  Dr.  C.  D. 
Meigs,  by  applying  a  cloth  wrapped  around  ice  over  the  epigastrium 
and  the  lower  part  of  the  sternum.  The  chief  danger  during  the 
attack  is  from  congestion  of  the  brain,  with  eftusion  of  serum  or 
extravasation  of  blood.  If  the  attack  is  severe,  and  the  features 
congested,  so  that  there  is  evident  danger  of  such  a  result,  cold 
applications  should  be  made  to  the  head,  derivatives  used  for  the 
extremities — as  sinapisms,  or  mustard  foot-baths — and  the  bowels 
should  be  speedily  opened  by  enemata. 


CHOREA.  415 


CHAPTER    XIV. 

CHOKEA. 

Chorea,  or  St.  Vitus'  or  St.  Guy's  dance,  is  a  nervous  affection, 
which  is  characterized  by  irregular  and  involuntary  muscular 
movements,  without  loss  of  consciousness.  The  movements  occur 
in  the  muscles  of  volition,  and  there  is  probably  no  one  of  them 
that  may  not  be  engaged,  though  some  are  more  frequently  affected 
than  others.  It  is  not  known  that  any  involuntary  muscle  is  ever 
involved,  though  Sir  William  Jenner  has  expressed  the  opinion 
that  occasionally  the  papillary  muscles  of  the  heart  are,  so  that,  by 
their  spasmodic  contractions,  they  produce  insufficiency  of  the 
mitral  valve.  This,  according  to  him,  affords  explanation  of  the 
fact  that,  in  certain  instances,  a  mitral  regurgitant  murmur  is 
heard,  which  disappears  about  the  time  that  the  external  movements 
cease.  It  is  rare,  however,  that  a  mitral  regurgitant  murmur, 
heard  during  chorea,  ceases  when  the  latter  terminates,  and  it  is 
not  improbable  that  in  such  cases  there  is,  after  all,  a  lesion  of  the 
valve,  due  to  recent  endocarditis,  whether  of  a  rheumatic  or  other 
origin.  For  a  valve  may  be  so  thickened  by  recent  inflammation 
as  to  cause  a  murmur,  and  after  a  few  weeks  or  months  the  infil- 
trating substance  be  so  absorbed  that  the  murmur  is  no  longer 
audible.  If  we  admit  the  fact  that  cardiac  bruits  occasionally 
appear  and  disappear  with  chorea,  this  explanation  seems  to  me 
more  plausible  than  that  of  Jenner.  Hillier  says,  in  reference  to 
this  subject :  "  My  own  experience  leads  me  to  doubt  the  existence 
of  dynamic  apex  murmurs  in  chorea,  that  is  to  say,  murmurs  pro- 
duced in  hearts  entirely  free  from  organic  change.  If  such  murmurs 
ever  occur,  they  are  certainly  rare.  Organic  murmurs  of  the  heart, 
on  the  other  hand,  are  common  in  chorea,  and  I  am  inclined  to 
believe  that  organic  disease  of  the  heart  often  exists  in  chorea 
when  there  is  no  murmur."  Ilillier  also  calls  attention  to  the  fact 
that  choreic  movements  are  irregular  ;  but  a  cardiac  bruit  occur- 
ring regularly  and  uniformly,  if  not  due  to  organic  disease,  would 
require  rhythmical  contractions  of  the  papillary  muscles  to  pro- 
duce it. 


6  years 

6  to  10 

10  to  15 

and  iiuder. 

years. 

years. 

.      81 

237 

1041 

,     10 

61 

118 

.       2 

26 

16 

416  CHOREA. 

Age. — Chorea  may  occur  at  any  period  of  life ;  but  while  it  is 
comparatively  rare  at  other  ages,  it  is  not  infrequent  in  childhood. 
A  large  majority  of  cases  are  between  the  fifth  year  and  puberty. 
Under  the  age  of  five  years,  the  proportionate  number  diminishes 
as  we  approach  the  time  of  birth,  and  it  is  rarely  observed  in  in- 
fants under  one  year.  The  j^oungest  in  the  statistics  of  Hillier  was 
three  months. 

In  1870,  at  the  Out-door  Department  of  Bellevue,  a  child  was 
presented  for  treatment,  who,  the  mother  stated,  had  had  chorea 
from  birth.  The  choreic  movements  were  no  doubt  observed  very 
early  in  infancy,  though  the  disease  probably  was  not  congenital. 
The  following  table  exhibits  the  relative  frequency  of  chorea  at 
difi:erent  ages  during  infancy  and  childhood  : — 


Children's  Hospital,  London,  Hillier 

M.  Rufz 

Out-door  Department,  Bellevue    . 

M.  See  collected  the  statistics  of  631  cases  occurrino;  in  the 
Children's  Hospital,  Paris,  and  from  them  concludes  that  the  maxi- 
mum frequency  of  chorea  is  between  the  sixth  and  tenth  years. 
Only  twenty-eight  of  his  cases  were  under  six  years,  the  remainder, 
503,  occurring  between  the  sixth  year  and  puberty. 

Causes. — The  profession  are  nearly  agreed  in  regard  to  certain 
causes  of  chorea,  while  there  is  a  diversity  of  opinion  in  reference 
to  others.  It  is  admitted  that  in  a  large  proportion  of  cases  there 
is  a  neuropathic  state,  which  antedates  and  predisposes  to  chorea. 
This  state  is  often  manifested  in  the  family  history  by  a  proneness 
to  aflt'ections  of  the  nervous  system,  and  in  the  individual  by  a 
highly  excitable  state  of  the  emotions,  so  that  he  evinces  joy,  grief, 
or  anger,  from  slight  causes. 

All  writers  admit  that  there  is  often  an  inherited  predisposition 
to  chorea.  In  27  of  48  cases  of  chorea,  E.adclifl:e  found  that  father, 
mother,  brother,  or  sister  had  been  or  was  the  subject  of  one  or 
other  of  the  following,  disorders :  paralysis,  epilepsy,  apoplexy,  h^'s- 
teria,  or  insanity.  The  children  of  parents  who  when  young  had 
chorea,  or  who  exhibit  proneness  to  ailments  of  the  nervous  system, 
arc  more  liable  to  chorea  than  other  children.  Hence  the  fact 
sometimes  observed,  of  different  children  in  the  same  family  be- 
coming affected  with  chorea  when  they  attain  the  age  at  which 
this  disease  ordinarily  occurs.  In  one  family,  in  my  practice, 
three  girls  at  different  times  were  affected. 

'  None  over  12  years  admitted. 


SEX — ANEMIA.  417 

Sex. — Tlie  emotions  are  strong  in  girls,  since  in  them  the 
nervous  system  predominates,  while  the  muscular  power  is  weaker 
than  in  boys.  Hence  a  partial  explanation  of  the  fact  which 
statistics  fully  establish,  that  the  proportion  of  choreic  boys  to 
girls  is  about  in  the  ratio  of  one  to  two  and  a  fraction.  I  have 
remarked,  in  this  city,  the  large  proportion  of  cases  in  school-girls 
between  the  ages  of  six  and  twelve  years;  the  severe  discipline 
and  confinement  of  the  public  schools  no  doubt  increasing  the 
strength  of  the  emotions,  and  weakening  the  control  of  the  will 
over  the  muscles. 

Proportion  of  Males  to  Females. 

27  to  73.  Hughes'  Digest  of  Cases  in  Guy's  Hosp.,  1846. 

138  to  393.  M.  See. 

25  to  40.  Out-door  Department,  Bellevue. 

276  to  499.  Children's  Hosp.,  Lond.  West  (Lumleian  Lect.). 


466  to   1005  =1  to  2.15. 

Uterine  Irritation. — The  peculiar  changes  occurring  in  the 
female  at  puberty  constitute  an  important  cause.  Hence  another 
reason  of  the  excess  of  female  cases.  Dysmenorrha?a  and  preg- 
nancy are  causes  of  a  large  proportion  of  cases  in  the  first  years  of 
puberty.  In  the  male,  on  the  other  hand,  the  changes  of  puberty 
do  not  appear  to  increase  the  liability  to  the  disease,  directlj'  or 
indirectly,  and  male  cases,  after  the  age  of  twelve  years,  are  com- 
paratively rare.  Radcliffe  states  {Reynolds''  Systoii  of  3Ied.)  that 
after  the  ninth  year,  females  are  more  liable  to  chorea  than  males, 
in  the  proportion  of  5  to  2;  while  before  the  ninth  year,  the  two 
sexes  are  equally  liable  to  it.  Carefully  prepared  statistics,  how- 
ever, notwithstanding  the  high  authority  of  RadcliflJe,  show  a 
preponderance  of  girls  under  the  age  of  nine  years,  though  not  as 
great  as  over  that  age.  In  the  Out-door  Department  at  Bellevue, 
of  35  patients  under  the  age  of  ten  years,  22  were  girls,  while  of 
20  from  the  age  of  ten  years  to  sixteen,  15  were  girls. 

According  to  West  (Lumleian  Lect.),  in  775  children  with  chorea, 
under  the  age  of  ten  years,  treated  in  the  Lond.  Children's  Hosp., 
64  per  cent,  were  girls. 

Anemia. — Among  the  most  common  predisposing  causes  of 
chorea  is  anaemia.  It  is  present  in  so  large  a  proportion  of  cases, 
exhibiting  itself  by  pallor  of  the  countenance  and  other  character- 
istic sigDs,  that  medicines  designed  to  improve  the  quality  of  the 
blood  are  among  the  vaost  valued  remedies.  The  peculiar  neuro- 
pathic state  already  alladed  to,  which  needs  only  a  slight  additional 
27 


418  CHOREA. 

cause  for  the  development  of  chorea,  is,  no  doubt,  largely  depen- 
dent on  impoverishment  of  the  blood,  if  it  is  not  sometimes  due 
entirely  to  it.  Among  the  poor  of  a  large  city  like  'New  York,  or 
in  hospital  practice,  the  proportion  of  anaemic  cases  of  chorea  is, 
for  obvious  reasons,  much  larger  than  would  appear  from  general 
statistics. 

Rheumatism. — Dr.  Copland,  M.  Bouteille,  and  afterwards  M. 
Germain  See,  in  a  more  extended  monograph,  directed  the  atten- 
tion of  the  profession  to  rheumatism  as  a  cause  of  chorea.  Subse- 
quent observations  have  established  the  fact  that  rheumatism,  or 
the  rheumatic  diathesis,  is  so  frequently  present  that  it  obviously 
sustains  an  important  relation  to  chorea,  though  in  what  manner  is 
not  fully  ascertained.  This  relation  betAveen  the  two  is  more  fre- 
quently observed  in  some  countries  than  in  others.  In  England  and 
France,  so  large  a  proportion  of  choreic  patients  present  the  history 
of  rheumatism  either  in  themselves  or  family,  that  certain  phy- 
sicians of  these  countries  believe  that  rheumatism  is  the  most 
common  cause  of  the  disease.  In  Germany,  on  the  other  hand, 
according  to  Romberg,  in  the  majority  of  cases  no  relation  can  be 
traced  between  chorea  and  rheumatism,  and  the  statistics  of  this 
city,  and  I  think  of  this  country,  correspond  with  those  in  Ger- 
many. 

Various  theories  have  been  promulgated  in  explanation  of  the 
relationship  of  the  rheumatic  and  choreic  diseases.  It  has  been 
suggested  that  chorea  is  due  to  rheumatism  of  the  brain  or  spinal 
cord.  This  is  simply  an  hypothesis,  the  truth  or  falsity  of  which 
can  only  be  ascertained  by  carefully  conducted  necropsies  ;  but  the 
theory  appears  improbable  in  view  of  all  the  facts.  Another  theory 
attributes  chorea  to  the  state  of  the  blood  which  is  present  in  those 
having  rheumatism  or  the  rheumatic  diathesis,  as  well  as  in  cer- 
tain other  conditions.  This  theory  is  enunciated  by  Dr.  Ogle,  as 
follows:  "Recognizing  the  frequent  existence  of  these  fibrinous 
deposits  or  granulations  on  the  heart's  valves  in  chorea,  I  should 
be  much  inclined  to  look  upon  these  post-mortem  appearances 
leather  as  results  of  some  antecedent  general  condition  of  the  blood, 
common  also  to  the  choreic  condition.  It  is  very  freely  recognized 
that  this  affection  is  frequently,  in  some  way  or  other,  connected 
with  that  condition  of  blood  which  obtains  in  what  we  call  anaemia, 
or  that  existing  in  rheumatic  constitutions.  In  both  of  these 
states  we  know  that  the  fibrin  of  the  blood  is  much  in  excess  (as 
also  it  is  in  pregnane^',  another  condition  looked  upon  as  obnoxious 
to  chorea) ;  and  in  these  states  we  know  that  the  fibrin  with  which 


RHEUMATISM.  419 

the  blood  is  surcharged  is  verj  prone  to  be  readily  precipitated, 
either  owing  to  its  superalnmdance,  or  from  other  obscure  and 
acquired  properties  .  .  .  upon  the  heart's  walls  or  valves.  May 
not  this  hyperinosis  be  the  explanation  of  the  coincidence  alluded 
to?"  {British  and  Foreign  Mal.-Chir.  licv.,  January,  1868) — namely, 
the  occurrence  of  chorea  in  those  affected  with  rheumatism.  Others 
still  hold  that  chorea  is  the  result  of  the  heart  disease,  and  not 
directly  of  rheumatism,  occurring  when  the  heart  is  aftected  from 
other  causes,  as  well  as  when  the  lesion  has  a  rheumatic  origin. 
This  theory  is  plausible,  and  probably  to  a  certain  extent  correct. 
Heart  lesions,  observed  in  children,  result  from  scarlet  fever  in  a 
considerable  proportion  of  cases,  though,  it  is  true,  the  endocarditis 
and  pericarditis  of  scarlet  fever  are  believed  often  to  have  a  rheu- 
matic origin,  occurring,  in  some  instances,  from  scarlatinous  rheu- 
matism, but  in  other  cases  from  scarlatinous  uraemia.  Occasionally 
also  the  heart  disease  appears  to  have  occurred  independently  of 
both  rheumatism  and  scarlet  fever.  Thus  in  a  fatal  case  of  chorea 
with  valvular  disease,  related  to  the  Lond.  Path.  Soc,  April  6, 
1869,  the  child  was  always  healthy  up  to  the  present  illness  (chorea), 
and  tliere  was  no  history  of  rheumatism  in  the  family.  The  more 
observations  accumulate,  the  more  important  does  heart  disease  in 
itself  appear  as  a  cause  of  chorea.  In  nearly  all  recorded  cases  of 
fatal  chorea,  which  were  supposed  to  be  due  to  rheumatism,  and  in 
which  post-mortem  examinations  were  made,  vegetations  have 
been  discovered  upon  the  valves — aortic  or  mitral.  We  shall  see 
that  certain  eccentric  causes  of  irritation  aid  in  producing  chorea, 
and  may  not  the  valvular  disease,  or  the  endocarditis  which  causes 
the  valvular  lesion,  operate  in  a  similar  manner  as  a  cause  ?  We 
know  that  in  the  adult  severe  cardiac  disease  often  profoundly 
aifects  the  nervous  system,  perhaps  in  consequence  of  the  irregular 
and  embarrassed  circulation  ;  and  certainly  in  the  child  a  similar 
cause  would  be  likely  to  produce  a  more  decided  eifect. 

But  there  is  an  ingenious  theory  which  attributes  chorea  to 
minute  emboli  detached  from  vegetations  on  the  valves,  and 
arrested  by  capillaries  in  the  corpora  striata,  or  other  portion  of 
the  cerebro-spinal  axis.  Since  attention  was  directed  to  this 
matter,  emboli  have  been  found  in  one  case  in  the  medulla  oblon- 
gata, although  this  portion  of  the  spinal  axis  appeared  healthy  to 
the  naked  eye.  Further  observations  are  necessary  in  order  to 
determine  how  much  truth  there  is  in  this  theory ;  but  it  seems 
probable,  for  reasons  to  be  stated,  that  if  capillary  embolism  does 
cause  chorea,  it  is  only  in  a  limited  number  of  cases,  and  that 


420  ■  CHOREA. 

therefore  those  British  observers  who  regard  it  as  the  common 
cause,  have  been  led  into  error  by  the  large  proportion  of  choreic 
cases  which  are  complicated  by  valvular  lesions  in  their  climate. 

That  embolism  is  not  a  common  cause,  if  indeed  a  cause  at  all, 
appears  probable  from  the  following  facts:  First.  In  many  cases 
of  chorea  there  are  no  vegetations,  or  other  appreciable  lesion, 
which  could  give  rise  to  emboli.  Secondly.  Most  patients  recover, 
and  some  speedily,  by  treatment,  which  we  would  not  expect  if 
the  cause  were  embolism.  Thirdly.  Embolism  is  not  infrequent 
in  the  cerebral  vessels  of  the  adult,  without  the  occurrence  of 
chorea.  Indeed,  the  conditions  which  produce  embolism  are  much 
more  common  in  adults  than  in  children,  while  the  reverse  is  true 
as  regards  the  liability  to  chorea.  Fourthly.  Dogs  sometimes 
have  chorea,  but  the  injection  of  minutely  divided  fibrin  or  other 
substance  in  the  veins  of  the  dogs  is  not  followed  by  chorea  as  one 
of  the  phenomena.  Fifthly.  Were  capillary  emboli  the  cause,  we 
would  expect  to  find  an  occasional  embolus  in  the  larger  vessels 
of  the  brain,  so  as  to  be  appreciable  to  the  naked  eye ;  but  I  find 
no  examples  of  this  in  all  the  recorded  autopsies  which  I  have 
been  able  to  consult.  Moreover,  it  seems  improbable  that  capillary 
embolism,  when  producing  no  lesion  appreciable  to  the  naked  eye, 
would  so  arrest  the  circulation,  and  disturb  the  function  of  the 
brain  or  spinal  cord,  as  to  cause  chorea,  for  the  ill  eft'ects  of  such  • 
an  obstruction  would  be  likely  to  be  obviated  by  the  numerous 
anastomoses. 

It  is  obviously  better,  in  the  present  state  of  uncertainty  regard- 
ing the  exact  relation  of  rheumatism  and  valvular  disease  to  chorea, 
to  postpone  the  acceptance  of  any  theory  till  the  minute  anatomy 
of  chorea  has  been  as  fully  investigated  as  has  its  clinical  history. 

Fright. — A  not  infrequent  exciting  cause  of  chorea  is  sudden 
and  profound  emotion,  especially  fright.  All  statistics  give  fright 
as  the  cause  of  a  certain  proportion  of  cases,  though  there  are 
usually  other  potential  co-operating  causes,  as  anajmia  or  valvular 
disease.  Fright  was  stated  as  the  cause  of  chorea  in  31  of  the 
100  cases  occurring  in  Guy's  Hospital,  reported  by  Hughes,  or  in 
nearly  one  in  three.  Eut  the  statistics  of  other  observers  do  not 
give  60  large  a  proportion  of  cases  originating  in  this  way.  Chorea 
may  commence  within  a  few  hours  after  the  fright,  or  not  till  the 
lapse  of  several  days  (eight  or  ten).  If  several  weeks  have  passed 
since  the  fright,  as  in  some  reported  cases,  the  chorea  is  probably 
due  to  other  causes.  In  rare  instances,  chorea  is  said  to  have  been 
caused  by  sudden  and  excessive  joy. 


INTESTINAL    IRRITATION,  421 

Imitation. — Under  nnusual  circumstances,  especially  in  a  state 
of  sreat  mental  excitement,  imitation  has  been  known  to  cause  a 
form  of  chorea,  llccker  describes  an  epidemic  of  it,  occurring  in 
the  middle  ages,  and  spreading  through  villages.  In  modern 
times  it  is  rare  that  chorea  originates  from  this  cause,  nevertheless 
occasional  examples  have  been  recorded. 

Hut  the  disease  which  occurs  from  imitation  differs  from  the 
ordinary  form,  and  lias  been  termed  chorea  major;  while  chorea 
proper,  which  is  the  subject  of  this  article,  is  sometimes  designated, 
in  contradistinction,  chorea  minor. 

In  chorea  major,  the  patient  leaps,  dances,  or  whirls  like  a  top. 
It  has  its  origin  commonly  in  religious  excitement,  and  spreads  by 
imitation  almost  in  the  manner  of  an  infectious  disease.  The 
epidemic  of  the  middle  ages  was  a  chorea  major.  I  have  not  been 
able  to  find  any  account  of  cases  spreading  by  imitation,  in  modern 
times,  which  were  not  examples  of  the  same  form  of  chorea.  Thus 
in  the  Edin.  Journ.  of  Med.  and  Surg,  for  July,  1839,  there  is  a 
clear  description  of  chorea  major,  occurring  successively  in  five 
children  in  the  same  family.  Dr.  Dewar,  the  attending  physician, 
states  that  one  of  the  children  whom  he  was  called  to  see  was 
sitting  near  the  fireplace,  when  her  head  dropped  on  her  chest, 
and  she  aj^peared  to  doze  some  minutes.  In  the  m(jantime  the 
respiration  became  a  little  accelerated,  the  face  altered  and  flushed, 
the  eyes  wild.  In  less  than  one  minute  she  bounded  from  one 
extremity  of  the  apartment  to  the  other,  leaping  over  chairs,  a 
chest,  and  then  throwing  herself  upon  the  floor;  she  attempted  to 
stand  upon  her  head,  rolled  upon  the  floor,  and  then,  rising,  ran 
with  extreme  swiftness  in  the  room,  till  she  finally  fell  again  on 
the  floor,  where  she  remained  motionless  some  minutes.  Then, 
recovering,  she  noticed  those  who  surrounded  her,  and  asked  of 
her  sister  a  toy,  which  she  had  allowed  to  fall.  The  whole 
paroxysm  lasted  twenty  minutes. 

Obviously,  the  symptoms  of  chorea  major  differ  materially  from 
those  of  chorea  proper,  and  it  is  a  question  whether  it  should  have 
the  same  generic  name.  It  is  a  curious  and  interesting  disease  in 
its  psychical  and  pathological  aspects,  but  it  is  so  rare  in  modern 
times  that  a  knowledge  of  it  is  of  little  practical  importance. 

Intestinal  Irritation. — In  rare  instances  intestinal  worms  cause 
chorea,  though  in  these  cases  there  have  usually  been  some  co- 
operating causes.  The  following  is  an  example,  related  by  Mr, 
Ogle  {Land.  3Icdico-Chir.  Rev..,  Jan.  1868):  Ellen  L.,  9  years  old, 
had  been  under  treatment  about  a  month  with  chorea,  rheumatisni, 


422  CHOKEA. 

and  worms.  She  had  not  slept  in  four  days,  and  there  was  constant 
spasmodic  movement  of  the  body  and  face.  Her  general  condition 
was  very  unpromising.  As  she  had  passed  portions  of  a  tapeworm 
at  intervals  during  the  last  three  months,  one  drachm  of  the  oleum 
filicis  maris  was  administered  in  mucilage,  which  caused  the 
expulsion  of  the  entire  worm.  From  that  time  she  fully  and 
rapidly  recovered  from  the  chorea,  though  a  mitral  murmur 
remained. 

Lesions  or  Brain  and  Spinal  Cord. — N'early  all  standard  authors 
who  reject  embolism  as  a  cause  of  chorea,  believe  there  is  no 
anatomical  cause  of  the  disease  located  in  the  cerebro-spinal  axis. 
In  other  words,  they  regard  chorea  as  one  of  the  neuroses.  This 
view  is  probably,  in  the  main,  correct ;  but  experiments,  and  also 
occasional  cases,  establish  the  fact  that  if  not  true  chorea,  at  least 
choreiform  movements,  now  and  then  result  from  a  structural 
affection  of  the  nervous  centres. 

Experiments  on  certain  of  the  lower  animals  demonstrate  that 
irregular  muscular  movements  may  be  produced  by  traumatic 
injury  of  certain  portions  of  the  cerebro-spinal  axis,  as  the  corpora 
quadrigemina,  crura  cerebri,  pons  Varolii,  crura  cerebelli,  thalami 
optici,  parts  of  the  medulla  oblongata,  and  the  upper  portion  of  the 
spinal  cord.  Pressure  on  the  projecting  part  of  the  medulla  oblon- 
gata of  an  acephalous  monster  also  causes  convulsive  movements. 
At  the  meeting  of  the  N".  Y.  Acad,  of  Medicine,  April  20,  1871, 
Prof.  Post  related  the  case  of  a  child  who  was  struck  with  a  billet 
of  wood,  over  the  occiput,  and  chorea  followed,  due,  in  all  proba- 
bility, to  the  injury  of  the  brain  which  resulted. 

If  irregular  muscular  movements,  choreic  or  choreiform,  result 
from  traumatic  injury  of  certain  portions  of  the  nervous  centres, 
may  they  not  also  occasionally  occur  from  lesions  of  the  same  parts 
produced  by  disease?  Sir  Benj.  Brodie  relates  the  case  of  a  choreic 
girl,  dying  in  St.  George's  Hospital  {London  Lancet^  Dec.  19,  1840), 
in  whom,  after  a  careful  post-mortem  examination,  the  only  morbid 
appearance  observed  was  a  tumor  the  size  of  a  hazelnut,  connected 
with  the  pineal  gland.  Dr.  Broadbent  described  another  case  be- 
fore the  London  Pathological  Society  (vol.  xiii.,  page  246,  Trans- 
actions), in  Mdiich  a  tumor  was  found  arising  from  the  centre  of  the 
spinal  cord ;  and  Chambers  one  in  which  tubercles  were  imbedded 
in  the  cord.  Romberg  quotes  from  Frerichs  a  case  in  which  the 
medulla  oblongata  was  pressed  upon  by  an  enlarged  odontoid  pro- 
cess ;  and  Dr.  Aitken  {Glasgow  Med.  Journ.,  vol.  i.)  one  in  which 
the  specific  gravity  of  the  thalamus  opticus  and  corpus  striatum 


ANATOMICAL    CHARACTERS.  423 

was  greater  on  one  side  than  on  the  other.  Rilliet  and  Barthez 
relate  other  similar  cases,  and  add:  "  We  may  conclude,  from  these 
diiFerent  cases,  that  there  exist  two  species  of  chorea :  the  one 
essentially  a  simple  neurosis,  while  the  other  depends  on  an  altera- 
tion of  the  encephalo-rachidian  system.  In  a  word,  it  is  of  chorea 
as  of  convulsions,  that  it  is  sometimes  idiopathic,  sometimes  symp- 
tomatic." Still,  the  cases  in  which  it  is  symptomatic  are  so  few, 
that  it  is  proper  to  consider  chorea,  as  it  ordinarily  occurs,  one  of 
the  neuroses  until  the  microscope  detects  some  anatomical  cause 
in  the  cerebro-spinal  system  of  which  we  are  now  ignorant. 

Anatomical  Characters, — So  far  as  ascertained,  chorea  has  no 
certain  anatomical  characters.  As  we  have  seen,  lesions  are  some- 
times present  which  probably  sustain  a  causative  relation  to  the 
disordered  muscular  action,  and  others  are  sometimes  observed 
which  are  neither  a  cause  nor  result,  their  presence  being  a  coinci- 
dence. But  there  are  two  lesions  which,  though  often  absent, 
have  been  observed  in  so  large  a  proportion  of  fatal  cases  that  they 
are  justly  regarded  as  an  occasional  result  when  chorea  is  severe. 
Dr.  Hughes,  of  London,  collected  records  of  the  post-mortem  ap- 
pearances of  14  cases,  with  the  following  result  as  regards  the 
cerebro-spinal  axis :  Brain,  14  cases :  healthy,  4  cases ;  only  con- 
gested, 3  cases ;  softened  in  part  or  entirely,  6  cases  (some  of  these 
also  congested).  In  some  of  these  cases  those  occasional  results  of 
congestion,  namely,  transudation  of  serum  and  extravasation  of 
blood,  in  greater  or  less  quantity,  were  also  observed.  Spinal  cord: 
healthy,  3  cases ;  congested,  2  cases  (one  slightly,  in  the  other  the 
engorged  vessels  were  large  and  numerous) ;  softening  in  medulla 
oblongata,  1  case  ;  softening  opposite  fourth  and  fifth  vertebrae,  12 
cases.  In  one  there  was  soft,  in  another  firm  adhesion  of  the  spi- 
nal meninges,  and  in  one  it  is  stated  that  the  rachidian  fluid  was 
opaque.  Of  sixteen  fatal  cases  of  chorea  occurring  in  St.  George's 
Hospital,  "  congestion  (more  or  less  complete)  of  the  nervous  cen- 
tres (brain  or  spinal  cord,  or  both)  was  met  with  in  six  cases." 
There  was  softening  of  certain  parts  of  the  brain  in  one  case,  and 
of  the  spinal  cord  in  another.  (Ogle,  Brit,  and  For.  3Iedico-Chir.  Bev., 
Jan.  1868.)  Other  statistics  of  the  anatomical  character  of  fatal 
chorea  correspond,  in  the  main,  with  those  of  Hughes  and  Ogle. 
These  lesions  are  probably  not  present  in  ordinary  cases,  occurring 
only  when  the  choreic  movements  are  so  severe  that  the  patient  is 
deprived  of  needed  repose,  and  the  important  functions  of  the 
economy,  as  the  circulation  and  nutrition,  are  seriously  disturbed. 

The  post-mortem  examination  of  other  parts  besides  the  cerebro- 


424  CHOREA. 

spinal  axis  furnishes  a  negative  result,  if  we  except  sucli  affections 
as  have  heen  ascertained  to  act  as  causes  of  chorea.  What  portion 
of  the  nervous  centre  is  chiefly  involved  in  chorea  is  uncertain. 
Some,  as  Sir  Benj.  C.  Brodie  {London  Lancet^  Dec.  19,1840),  con- 
sider chorea  a  disease  of  the  nervous  system  generally,  while  others 
have  attributed  it  to  disease  or  disorder  of  a  certain  part,  as  the 
corpus  striatum,  cerebellum,  etc.  Finally,  it  is  stated  that,  in 
late  experiments  on  choreic  dogs,  the  movements  do  not  cease 
when  the  spinal  cord  is  severed  from  the  brain,  nor  also  on  division 
of  the  posterior  roots  of  the  spinal  nerves.  (Legros  et  Onimus,  Rech. 
sur  les  mouvements  choreiformes  du  chien,Acad.  des  Sci.,9  Mai, 
1870',  Lyons  3Ied.  Journ.,  June  5, 1870.)  In  these  cases,  therefore, 
the  part  of  the  axis  which  is  in  fault  would  appear  to  be  solely  the 
spinal  cord. 

Symptoms. — Chorea  is  partial  or  general.  It  is  partial  when  it 
aflfects  a  few  muscles,  or  groups  of  muscles,  as  those  of  one  arm, 
the  face  or  neck,  or  of  one  eye.  It  is  designated  general,  when  all 
the  limbs,  and  certain  of  the  muscles  of  the  face  and  trunk,  are 
involved.  Statistics  show  that  partial  chorea  occurs  more  fre- 
quently on  the  left  than  on  the  right  side,  and  in  general  chorea 
the  movements  on  the  left  side  are  apt  to  predominate.  The  com- 
mencement is  usuall}^  gradual.  Even  when  finally  chorea  becomes 
general,  certain  muscles  only  are  aflJected  in  the  commencement  in 
ordinary  cases.  The  child  in  whom  this  disease  is  about  to  begin 
is  observed  to  be  fretful  and  impatient  from  slight  causes,  and  the 
irregular  muscular  action  at  first  is  apt  to  be  misunderstood  by  the 
parents,  who  reprimand  him  for  his  supposed  fidgety  habit.  In 
exceptional  instances,  especially  when  the  cause  is  a  sudden  and 
profound  emotion,  the  commencement  is  abrupt,  and  the  disease  is 
severe  and  general  from  the  first. 

In  a  majority  of  cases  the  muscles  which  are  primarily  affected 
are  those  of  the  face,  neck,  fingers,  or  hand  on  the  left  side. 
Sydenham  erred,  unless  the  clinical  history  of  chorea  has  changed 
during  the  last  two  centuries,  when  he  stated  as  the  common  fact 
that  a  tottering  gait  is  its  first  manifestation ;  but  now  and  then 
such  a  case  does  occur.  "Wherever  the  choreic  movements  first 
appear,  other  muscles  are  soon  involved,  so  that  in  the  course  of  a 
few  weeks,  sometimes  of  a  few  days,  all  the  muscles  that  particir 
pate  are  engaged. 

A  muscle  aft'ected  by  chorea  alternately  contracts  and  relaxes, 
but  less  forcibly  and  rapidly  than  in  eclampsia,  and  the  movement 
is  partly  controlled  by  volition.     This  produces  an  unsteady  and 


SYMPTOMS.  425 

tremulous  action  of  the  part,  wliethor  a  limh,  the  neck,  or  face ; 
which  at  once  arrests  attention,  and  indicates  the  nature  of  the 
disease.  The  result  is  similar,  as  regards  the  muscular  action, 
whether  the  jDatient  wills  a  movement,  or  attempts  to  control  those 
which  chorea  produces. 

If  the  case  is  of  ordinary  severity,  the  movements  continue  with 
but  momentary  intermissions,  except  during  sleep,  when  they 
ordinarily  cease.  In  grave  cases  patients  are  often  deprived  of  the 
proper  amount  of  sleep  in  consequence  of  the  severity  and  per- 
sistence of  the  muscular  action,  and  in  exceptional  instances, 
especially  when  the  result  is  fatal,  the  movements  continue  in 
sleep,  but  the  sleep  is  not  sound,  and  is  frequently  interrupted.  In 
profound  sleep,  the  muscles  are  probably  always  in  repose. 

The  older  writers  have  left  us  graphic  descriptions  of  those 
diseases  which  have  striking  external  manifestations,  though  often 
with  somewhat  of  exaggeration.  Sydenham  says  of  chorea :  "  The 
patient  cannot  keep  it  (his  hand)  a  moment  in  the  same  place; 
whether  he  lay  it  upon  his  breast,  or  any  other  part  of  the  body, 
do  what  he  may,  it  will  be  jerked  elsewhere  convulsively.  If  any 
vessel  filled  with  drink  be  put  into  his  hand,  before  it  reaches  his 
mouth,  he  will  exhibit  a  thousand  gesticulations,  like  a  mounte- 
bank. He  holds  the  cup  out  straight,  as  if  to  move  it  to  his 
mouth,  but  has  his  hand  carried  elsewhere  by  sudden  jerks.  Then 
perhaps  he  contrives  to  bring  it  to  his  mouth,  and  if  so,  he  will 
drink  the  liquid  off  at  a  gulp,  just  as  if  he  were  trying  to  amuse 
the  spectators  by  his  antics !" 

In  severe  general  chorea  a  similar  description  is  applicable  to  the 
movements  of  the  legs  and  features.  Grimaces  and  distortions  of 
the  features  occur,  while  the  gait  is  halting  and  unsteady,  or  it  is 
impossible  to  walk,  and  the  patient  lies  or  sits.  The  speech  is 
slow,  thick,  and  indistinct,  in  consequence  of  the  muscles  of  the 
tongue  and  larynx  becoming  engaged,  and  even  mastication  and 
deglutition  are  rendered  difficult.  The  imperfect  speech  in  chorea 
is  attributed  partly,  however,  to  the  impairment  of  the  mental 
faculties.  Chorea,  except  in  mild  cases,  is  accompanied  by  other 
symptoms  referable  to  the  nervous  system.  More  or  less  impair- 
ment of  the  mental  faculties  occurs  in  severe  and  protracted  chorea, 
exhibiting  itself  in  dulness  or  aimthy.  The  countenance  sometimes 
presents  in  aggravated  cases  almost  the  appearance  of  idiocy.  The 
muscles,  instead  of  becoming  hypertrophied,  and  more  powerful  by 
their  frequent  contraction,  grow  softer,  more  flabby,  and  weaker. 
Indeed,  a  partial  paralysis  sometimes  results,  so  that  a  degree  of 


426  CHOREA. 

numbness  is  experienced  in  the  affected  part,  and  the  limb  when 
raised  cannot  be  sustained.  Pain  is  not  a  symptom  of  chorea,  bnt 
fugitive  rheumatic  or  neuralgic  pains  are  sometimes  experienced. 
Derangement  of  the  digestive  function,  exhibited  by  a  poor  or 
capricious  appetite,  constipation,  etc.,  are  common. 

The  urine  of  choreic  patients  has  been  examined  by  Drs,  "Walsh, 
Ford,  Bence  Jones,  Handfield  Jones,  Radcliffe,  and  others,  and  its 
elements  have  been  found  in  most  cases  to  vary  from  their  normal 
quantity.  Dr.  Handfield  Jones  read  a  paper  before  the  Clinical 
Society  of  London,  in  1871  {London  Lancet^  July,  1871),  on  two 
cases  of  chorea  in  which  he  had  made  careful  chemical  analysis  of 
the  urine,  with  the  following  result:  During  the  height  of  the 
disease  the  amount  of  the  urine  was  much  in  excess  of  what  it  was 
when  the  disease  had  ceased ;  the  amount  of  urea  excreted  during 
the  choreic  period  was  enormous ;  the  amount  of  phosphoric  acid 
excreted  when  the  choreic  symptoms  were  at  their  maximum  was 
excessive,  but  the  quantity  was  less  than  the  average  during  con- 
valescence ;  a  moderate  amount  of  uric  acid  during  the  disease,  but 
none  upon  recovery. 

Prognosis  ;  Course. — Chorea,  though  obstinate  and  often  incura- 
ble in  adults,  usually  terminates  favorably  in  children  in  three  or 
four  months.  Bouchut  considers  its  ordinary  duration  at  from 
thirty  to  fifty  days,  which  is  certainly  shorter  than  the  average 
duration  in  this  country,  except  as  the  disease  is  materially 
abridged  by  treatment.  The  same  author  states  that  it  may  con- 
tinue only  twenty-four  hours,  or  some  days,  as  he  has  observed  in 
the  convalescence  from  scarlet  fever.  But  tremulousness  of  the 
muscles  occurring  in  the  state  of  weakness  following  a  grave 
disease,  and  abating  as  the  general  health  is  restored,  I  should  not 
consider  as  properly  choreic,  any  more  than  that  occurring  from 
over-fatigue.  As  the  choreic  movements  gradually  increase  in  the 
initial  period  till  a  certain  maximum  is  reached,  so  their  decline 
is  gradual.  There  are  temporary  variations  also  throughout  the 
disease  as  regards  the  extent  of  the  movement,  which  are  aggra- 
vated by  mental  excitement,  bodily  fatigue,  certain  functional 
derangements,  especially  of  digestion,  and  sometimes  from  causes 
which  are  not  apparent. 

Though,  as  a  rule,  chorea  in  children  ordinarily  terminates 
favorably  under  different,  and  even  injurious,  modes  of  treatment, 
there,  are  exceptional  cases.  Romberg  relates  the  history  of  a 
patient  who  died  at  the  age  of  seventy-six  years,  having  had  chorea 
since  the  age  of  six  years.     In  chorea  limited  to  a  few  muscles,  or 


DIAGNOSIS.  427 

a  group  of  muscles,  the  prognosis  is  more  doubtful  than  when  it 
affects  a  large  number,  since  in  the  former  case  the  cause  is  more 
apt  to  be  some  lesion  of  the  cerebro-spinal  axis.  Thus  chorea 
involving  only  certain  muscles  of  the  neck  or  of  the  eyes  is  some- 
times due  to  this  cause,  and  is  then  very  obstinate. 

Again,  observations  demonstrate  that  chorea,  when  at  first  in 
all  probability  strictly  a  neurosis,  but  of  a  protracted  and  grave 
character,  may  give  rise  to  a  central  organic  disease.  This  is  the 
course  of  most  of  the  fatal  cases,  congestion,  softening,  or  other 
lesion  occurring  over  a  greater  or  less  extent  of  the  nervous  centres. 
Radcliffe  has  known  cerebral  meningitis  to  supervene  in  two 
instances.  With  the  occurrence  of  a  lesion  of  the  cerebro-spinal 
axis,  new  symptoms  arise,  such  as  headache,  convulsions,  delirium, 
and  paralysis,  and  the  choreic  movements  cease  or  continue,  accord- 
ing to  the  nature  of  the  lesion. 

Chorea,  like  certain  other  diseases,  either  of  a  nervous  character, 
or  having  a  nervous  element,  is  more  or  less  modified  by  intercur- 
rent inflammatory  and  febrile  affections.  The  oft-quoted  expres- 
sion from  Hippocrates,  fehris  accedens  solvit  spasmos,  observations 
show  to  be  founded  in  fact,  the  most  frequent  example  of  which 
occurs  in  pertussis.  In  chorea  the  movements,  as  a  rule,  are  either 
rendered  milder  or  they  cease  as  long  as  the  febrile  excitement 
continues ;  but  there  are  exceptions,  and  the  subsequent  course  of 
the  disease  is  not  modified. 

Diagnosis. — This  is  not  difficult  in  ordinary  cases.  The  irregular 
movements,  with  consciousness  preserved,  enable  us  to  make  a 
diagnosis  at  sight.  In  its  commencement,  and  when  it  continues 
in  an  unusually  mild  form,  chorea  might  be  overlooked  by  the 
physician,  as  it  often  is  by  the  parents,  the  movements  being  at- 
tributed to  a  fidgety  habit ;  but  medical  advice  is  seldom  sought 
till  the  movements  are  so  pronounced  that  it  is  impossible  to  err, 
except  through  gross  ignorance  or  carelessness. 

It  is  important  to  determine  when  chorea  merges  in  an  organic 
disease,  and  also  whether  there  is  a  local  cause  of  the  chorea.  A 
careful  and  intelligent  study  of  the  symptoms  and  history  of  the 
case  is  requisite  in  order  to  a  correct  diagnosis  in  these  particulars. 

Treatment.  Begimenal. — As  chorea  in  a  large  proportion  of 
cases  occurs  in  a  state  of  anaemia,  and  the  vital  forces  are  ordi- 
narily more  or  less  reduced,  obviously  the  regimen  should  be  such 
as  invigorates  the  system.  Fresh  air  and  out-door  exercise,  active 
or  passive,  according  to  circumstances,  with  the  avoidance  of  undue 
excitement,  are  requisite ;  and  the  diet  should  be  nutritious,  but 


428  CHOREA. 

plain  and  unirritating.  The  various  functions  should  be  preserved 
so  far  as  possible  iu  their  normal  state.  In  exceptional  instances, 
when  the  choreic  movements  are  violent,  the  patient  should  lie  in 
bed,  and  the  muscular  action,  if  so  constant  and  excessive  as  to 
deprive  him  of  the  requisite  sleep,  should  be  restrained  by  light 
and  well-padded  splints. 

JfedicinaL — Sometimes  among  the  co-operating  causes  is  one  of 
a  local  nature,  which  is  susceptible  of  removal,  as  a  carious  and 
painful  tooth,  intestinal  worms,  etc.,  and  measures  calculated  to 
effect  this  are  obviously  required.  Allusion  has  alread}-  been  made 
to  a  case  iu  which  the  employment  of  the  oleum  filicis  maris,  and 
expulsion  of  a  tapeworm,  effected  a  speedy  cure. 

The  remedy  which  has  been  most  employed  in  chorea,  and  wliieli 
in  consequence  of  the  antemia  is  plainly  indicated  in  a  large  pro- 
portion of  cases,  is  iron.  It  does  not  interfere  with  the  employ- 
ment of  other  remedies  wbich  have  a  more  specific  effect.  Xcarly 
all  the  ferruginous  preparations  have  been  prescribed  in  different 
cases  with  benefit.  Radcliffe,  who  justly  ranks  as  one  of  the  firet 
authorities  in  nervous  diseases,  gives  the  preference  to  the  iodide 
of  iron,  believing  that  iodine,  as  well  as  iron,  exerts  a  curative 
influence.  I  have  of  late  inclined  to  the  use  of  the  ammonio- 
citrate,  as  it  is  easy  of  administration  in  simple  syrup,  and  is  well 
tolerated. 

Arsenic,  highly  extolled  by  Romberg  and  others,  is  a  remedy  of 
undoubted  value.  It  is  convenientlv  o-iven  in  Fowler's  solution. 
It  should  be  administered  in  doses  of  three  to  five  drops  three  times 
daily,  after  the  meals,  as  in  the  treatment  of  cutaneous  or  other 
aftcctions.  Eadclifle  has  administered  by  subcutaneous  injection 
Fowler's  solution,  diluted  with  an  equal  quantity  of  water,  in  a 
few  cases  of  obstinate  local  chorea,  with  a  satisfactorv  result.  An 
adult  with  choreic  movements  in  one  side  of  the  neck  of  nine 
years'  duration  was  nearly  cured  by  fourteen  injections,  employed 
at  intervals  of  a  few  days,  the  quantity  employed  being  increased 
gradually  from  three  to  fourteen  minims  of  the  solution.  Another 
remedj-  of  undoubted  value  is  strychnia.  Trousseau,  who  prescribed 
it  iu  most  cases,  and  highly  extolled  it,  employed  the  following 
formula: — 

R.  Strychnise  sxilphat.  gr.  j. 
Syr.  simplic.  oU^s.     Misce. 

A  child  of  the  ordinary  age,  say  ten  years,  takes  at  first  a  tea- 
spoonful  twice  or  three  times  daily,  at  uniform  intervals,  and  the 
dose  is  gradually  and  cautiously  increased  until  it  begins  to  pro- 


MEDICINAL.  429 

duce  physiological  effects.  Strychnia,  when  employed  to  the  extent 
of  causing  some  rigidity,  is  more  efficient  as  a  remedy,  hut  smaller 
doses  have  been  found  useful. 

Prof.  Hammond  {Diseases  of  the  Nervous  System^  p^g^  ^l^J  says: 
"My  main  reliance  is  on  strychnia,  which,  I  think  should  be  given 
in  gradually  increasing  doses,  somewhat  after  the  manner  recom- 
mended by  Trousseau.  .  .  .  This  plan  of  treatment  certainly  shortens 
the  duration  of  the  disease  very  materially,  and  causes  great  im- 
provement in  the  general  health  of  the  patient.  Sometimes  the 
effect  is  so  well  marked,  and  is  so  immediate,  that  it  is  not  neces- 
sary to  increase  the  doses  to  the  extent  of  causing  muscular  cramps, 
but  generally  the  full  therapeutical  effect  of  the  drug  is  not 
obtained  till  the  calf  of  the  leg  or  the  nucha  has  slicfht  tonic 
spasm.  I  have  never  seen  the  slightest  ill-consequence  follow  this 
mode  of  treatment,  and  the  doses  are  increased  so  gradually  that, 
with  careful  watching,  danger  need  not  be  apprehended."  Dr. 
Hammond  has  treated  thirtv-two  children  with  this  agent  without 
a  single  failure. 

But  as  chorea  terminates  favorably  with  smaller  and  safe  doses, 
even  if  the  time  required  is  longer,  it  does  not  seem  proper  to  re- 
commend its  employment  to  the  exter.,^  of  producing  pjhysiological 
effects  for  general  practice.  Bouchut,  speaking  upon  this  point, 
says :  "  But,  with  these  precautions,  strychnia  is  extremely  danger- 
ous, for  I  have  seen,  at  the  Ilopital  des  Enfants  Malades,  a  young 
girl  of  thirteen  years  die  in  tetanus,"  produced  by  an  increased 
dose  of  this  drug  (article  on  Chorea).  Dr.  West,  in  his  Lumleian 
Lectures,  also  says :  "I  have  seen  one  instance  in  which  its  employ- 
ment, while  it  failed  to  benefit  a  somewhat  severe  case  of  chorea, 
was  followed  by  two  attacks  of  violent  tetanic  convulsions,  which 
nearly  proved  fatal ;  "  and  he  adds,  "  the  twitching  of  the  limbs  of 
itself  prevents  our  becoming  aware  of  the  dose  being  excessive,  and 
a  child's  inability  to  describe  its  sensations  deprives  us  of  another." 
For  such  reasons,  Dr.  West  does  not  favor  the  employment  of  this 
agent.  Still,  any  agent  may  be  given  in  an  overdose,  and  it  is  not 
difficult  to  prescribe  strychnia  in  a  dose  which  will  be  efficient  and 
yet  safe  for  children  at  the  age  at  which  chorea  ordinarily  occurs. 
I  have  employed  bromide  of  potassium  in  a  few  cases,  but  with  so 
little  benefit  that  I  am  not  inclined  to  continue  its  use  for  this 
disease.  Others  have  not  been  more  successful.  However  effica- 
cious the  bromide  may  be  in  ejjilepsy,  it  does  not  apptear  to  be  a 
remedy  for  chorea. 

Cimicifuga,  first  employed  by  Jesse  Young  of  this  country,  is 


430  CHOREA. 

highly  esteemed  by  Philadelphia  physicians  in  the  treatment  of 
chorea.  I  have  employed  the  fluid  extract  in  doses  of  half  a  drachm, 
increased  to  one  drachm,  for  a  child  from  six  to  ten  years  of  age, 
and  though  it  benefits  some  cases,  it  has  no  appreciable  effect 
either  in  moderating  the  movements  or  abridging  the  duration  of 
others. 

Ether,  assafoetida,  valerian,  musk,  the  oxide  and  sulphide  of 
zinc,  turpentine,  tartar  emetic,  opium,  and  numerous  other  reme- 
dies, have  been  recommended,  and  some  of  them  have  seemed  use- 
ful in  certain  cases.  In  this  city  sulphate  of  zinc  has  been  frequently 
employed  as  a  remedy  for  chorea,  and  in  gradually  increasing  doses 
till  more  than  twenty  grains  were  administered  three  times  daily, 
but  it  has  not  appeared,  so  far  as  I  have  been  able  to  ascertain,  to 
exert  any  marked  influence  either  on  the  severity  or  duration  of 
the  choreic  movements.  Justice,  however,  requires  us  to  state 
that  Dr.  West,  who  has  written  most  recently  on  the  nervous  dis- 
orders of  children,  thinks  that  it  has  been  beneficial  in  certain 
cases  in  which  he  has  employed  it,  and  regards  it  on  the  whole  as 
the  best  remedy. 

Radcliffe,  who  has  had  ample  experience  in  the  treatment  of 
nervous  affections,  writes :  "  L:  an  ordinary  case  of  chorea  the 
plan  of  treatment  which  I  have  now  adopted  as  a  rule  for  some 
time  is  to  give  cod-liver  oil,  in  conjunction  with  hypophosphite  of 
soda,  making  the  draught  containing  the  latter  salt  the  vehicle  for 
the  administration  of  the  cod-liver  oil."  Sometimes  camphor  or 
the  sesquicarbonate  of  ammonia  is  added.  Of  more  than  thirty 
cases  treated  in  this  way,  the  average  duration  was  under  three 
weeks.  Radcliffe  began  to  prescribe  these  remedies  on  theoretical 
grounds,  believing  that  phosphorus  and  cod-liver  oil  were  re- 
quired to  restore  "  nerve  tone,"  and  the  result  of  this  treatment 
has  certainly  been  such  as  to  commend  it  to  the  profession.  To 
children  he  gives  from  five  to  eight  grains  of  the  hypophosphite  of 
soda  three  times  daily. 

In  those  severe  cases  in  which  the  choreic  movements  prevent 
the  proper  amount  of  sleep,  a  moderate  dose  of  hydrate  of  chloral 
may  occasionally  be  advantageously  administered. 

Electricity  has  been  many  times  employed  in  the  treatment  of 
chorea,  and  though  some,  cliiefl}'  electricians,  believe  that  it  has  a 
curative  effect,  others,  and  the  majority,  fail  to  see  any  material 
benefit  from  its  use. 

Cold  general  baths,  the  shower-bath,  frictions  along  the  spine, 
etc.,  have  been  employed  ;  but  the  local  treatment,  which  has  so 


INFANTILE    PARALYSIS.  431 

far  been  most  successful,  and  which  promises  to  supersede  all  others, 
consists  in  the  application  of  ether  spray  over  the  spine.  About 
two  ounces  of  ether  are  employed  at  each  sitting,  the  spray  being 
applied  from  an  atomizer  up  and  down  the  whole  length  of  the 
spine  if  the  chorea  is  general.  The  operation,  which  occupies 
from  ten  to  fifteen  minutes,  should  be  repeated  daily  or  every 
second  day.  Although  this  mode  of  treatment  is  quite  recent,  a 
considerable  number  of  cases  have  already  been  reported,  in  which 
the  spray  has  apparently  had  a  very  decided  efiect  in  controlling 
the  disease. 


CHAPTER  XV. 

INFANTILE  PARALYSIS. 

Paralysis  m  young  children,  especially  infants,  is  in  most 
instances  due  to  causes  which  seldom  produce  it  in  adults.  The 
principal  cause  of  it  in  the  adult,  namely,  cerebral  apoplexy,  is 
indeed  rare  in  children.  Paralysis  in  children  has  the  following 
recognized  causes:  1st.  A  change  in  the  blood,  not  fully  under- 
stood, induced  by  certain  grave  diseases,  as  diphtheria,  typhoid 
fever,  measles,  scarlet  fever,  etc.  2d.  Reiiex  influence.  The  func- 
tion of  some  part  of  the  system  is  in  some  way  disturbed,  and 
paralysis  occurs  in  certain  muscles,  may  be  at  a  distance  from  the 
cause,  and  it  disappears  when  that  cause  is  removed,  unless  it  has 
continued  too  long.  The  only  rational  explanation  is  found  in  the 
fact  of  a  continuous  connection  between  the  local  causes  and  the 
paralyzed  muscles  through  the  aiierent  and  efferent  nerves,  and 
the  nervous  centres.  3d.  An  anatomical  alteration  in  the  muscular 
fibres,  the  nerves  and  nervous  centres  remaining  unafiected.  This 
has  been  designated  myogenic  paralysis.  This  form  of  paralysis  is 
probably  often  of  a  rheumatic  nature.  We  see  a  similar  disease  in 
that  form  of  facial  paralysis  of  the  adult  which  results  from  long 
exposure  of  the  face  to  a  cold  wind.  4th.  A  cause  seated  in  the 
nervous  system,  either  congestion,  hemorrhage,  softening,  or  com- 
pression, whether  from  inflammatory  products  or  other  cause. 

Paralysis  occurring  as  a  symptom,  or  sequel  of  some  obvious 
local  or  general  disease,  as  diphtheria,  lesion  of  the  nervous  centres, 
etc.,  and  which  may  occur  at  any  age,  need  not  detain  us.  It  is 
described  in  connection  with  the  primary  diseases  on  which  it 


432  INFANTILE    PARALYSIS. 

depends.  But  there  is  a  form  of  paralysis  which  in  the  present 
state  of  our  knowledge  we  must  consider  an  idiopathic  disease,  and 
which  is  peculiar  to  the  first  years  of  life,  or  is  so  rare  at  other 
periods  that  it  is  proper  to  regard  it  as  strictly  a  disease  of  infancy 
and  early  childhood.  It  occurs  between  the  ages  of  six  months 
and  three  years. 

Symptoms. — The  previous  health  of  the  patient  is  usually  good. 
The  paralysis  does  not  always  commence  in  the  same  manner.  In 
some  it  begins  abruptly,  after  sound  sleep.  The  child  goes  to  bed 
well,  sleeps  through  the  night,  and  awakens  in  the  morning 
paralyzed.  I  have  known  it  to  occur  in  one  instance  after  sleep 
in  the  middle  of  the  day.  In  these  cases  there  has  sometimes  been 
an  exposure,  before  the  sleep,  to  wind  or  rain,  or  from  sitting  upon 
a  cold  stone.  In  other  and  the  majority  of  cases  the  paralysis  is 
preceded  by  a  very  decided  febrile  movement,  which  comes  on 
suddenly,  without  appreciable  cause,  and  after  a  few  days  the 
power  of  motion  is  found  to  be  lost  in  one  or  more  of  the  limbs. 
There  is  no  symptom  during  the  febrile  movement  to  indicate  any 
affection  of  the  brain:  consciousness  is  retained,  and  there  is  no 
more  headache  or  apparent  liability  to  convulsions  than  occurs  in 
other  pathological  states  accompanied  by  an  equal  amount  of  fever. 
In  whatever  way  the  paralysis  begins,  it  is  at  its  maximum  in  the 
commencement.  Occurring  as  by  a  stroke,  the  full  extent  of  the 
paralytic  state  is  exhibited  at  once,  and  so  far  as  there  is  any  sub- 
sequent change,  it  is  an  improvement,  as  regards  the  number  of 
muscles  affected,  and  the  degree  of  the  paralysis.  Most  frequently 
the  paralysis  affects  one  or  both  lower  extremities.  Occasionally 
one  of  the  upper  extremities  is  also  paralyzed  in  addition  to  the 
lower,  but  paralysis  of  an  upper  extremity  is  less  in  degree,  and 
disappears  sooner,  than  that  of  the  lower.  The  bladder  and  lower 
bowels  remain  unafiected,  since  only  the  muscles  of  volition  are 
involved.  Sensation  is  unimpaired  in  the  affected  limbs,  and'  in 
the  commencement  there  is  even  in  some  cases  a  state  of  hyper?es- 
thesia  (West).  The  febrile  movement,  which  precedes  and  accom- 
panies the  paralysis  in  certain  cases,  gradually  abates,  and  in  a  few 
days  nothing  abnormal  remains  except  the  loss  of  power  in  the 
affected  muscles.  These  muscles  are  in  a  flaccid  and  relaxed  state, 
so  that  the  limb  falls  by  its  weight  when  unsupported,  and  they  are 
usually  free  from  pain.  The  number  of  muscles  paralyzed  varies 
greatly  in  different  cases.  Only  one  muscle  or  a  single  group  of 
muscles  may  be  affected,  or,  on  the  other  hand,  both  the  extensor 
and  flexor  muscles  of  two  or  more  limbs.     In  the  opinion  of  Mr. 


PROGNOSIS  —  PROGRESS.  433 

Adams,  the  following  table  exhibits  the  groups  of  muscles  and 
single  muscles  most  fre(iuciitl3^  involved,  and  in  the  order  stated. 

Groups. 

1.  Extensors  of  toes,  and  flexors  of  the  foot. 

2.  Extensors  and  supinators  of  the  hand. 

3.  Extensors  of  leg,  and  with  them  usually  the  first  group. 

Single  Muscles. 

1.  Extensor  longus  digitorum  of  toes. 

2.  Tibialis  anticus. 

3.  Deltoid. 

4.  Sterno-mastoid. 

Prognosis — Progress. — The  paralysis  in  nearly  all  cases  soon 
begins  to  abate.  The  power  of  motion  returns  little  by  little,  and 
whatever  improvement  occurs  is  permanent.  There  is  no  retro- 
gression in  the  convalescence.  The  sooner  improvement  com- 
mences, the  more  favorable  is  the  prognosis.  In  the  most  favorable 
cases  there  is  complete  restoration  in  from  three  to  four  weeks. 
In  other  patients,  while  certain  of  the  muscles  regain  the  power 
of  motion,  other  muscles,  oftener  those  of  the  lower  extremity 
than  upper,  do  not  recover  their  function,  and,  unless  proper  reme- 
dial measures  are  employed,  and  even  with  them  in  certain  instances, 
atrophy  soon  commences.  The  temperature  of  the  paralyzed  limb 
falls  three,  five,  or  even  eight  degrees,  and  the  amount  of  blood 
which  circulates  in  it  is  diminished  so  that  the  pulse  of  the  limb  is 
feebler  and  its  vessels  smaller  than  in  health.  With  the  atrophy 
the  contractility  of  the  muscular  fibres  by  the  electric  current 
diminishes,  and  in  unfavorable  cases  after  a  time  powerful  induced 
and  even  primary  currents  have  no  appreciable  effect.  The  nutri- 
tion of  a  paralyzed  limb  is  always  imperfect,  and  if  the  paralysis 
occur  in  a  child,  its  growth  is  retarded.  Therefore  in  cases  of  pro- 
tracted or  permanent  infantile  paralj^sis  of  one  limb  a  disproportion 
occurs  both  in  diameter  and  length  between  it  and  that  on  the- 
opposite  side.  If  the  paralysis  continue,  the  ligaments  of  the 
paralyzed  limb  become  relaxed  and  lengthened.  West  mentions 
a  case  of  paralysis  of  the  deltoid  in  which  the  humero-scapular 
ligaments  were  so  extended  that  the  humerus  droj^ped  from  the 
glenoid  cavity,  so  as  to  increase  the  length  of  the  limb  three- 
fourths  of  an  inch.  In  the  paralysis  of  certain  muscles  of  the 
lower  extremity,  and  continuance  of  the  contractile  ]30wer  in 
28 


434  INFANTILE    PARALYSIS. 

others,  we  have  the  conditions  which  give  rise  to  club-feet,  and 
accordingly  this  deformity  is  the  common  result  of  the  paralysis 
when  it  is  not  cured. 

Etiology. — Opportunity  for  post-mortem  examinations  seldom 
occurs,  and  what  the  exact  pathological  state  is  which  causes  the 
paralysis  has  not  been  fully  ascertained.  As  most  of  the  cases 
occur  during  the  time  of  first  dentition,  it  was  long  believed  that 
this  physiological  process  was  the  chief  cause,  and  hence  the  term 
dental  paralysis  by  which  this  disease  was  designated.  It  is  now, 
however,  generally  admitted  that  the  evolution  of  the  teeth  is  not 
a  direct  cause,  and  can  only  operate  as  a  cause  by  increasing  the 
susceptibility  of  the  nervous  system.  The  brain  and  cerebral 
meninges  may  also  be  excluded  as  sustaining  any  causative  rela- 
tion to  the  paralysis.  There  is  no  symptom  indicating  that  they 
are  involved.  The  mind  remains  clear,  and  convulsions  are  no 
more  frequent  than  in  any  other  disease  attended  by  an  equal 
degree  of  febrile  reaction. 

Most  of  the  highest  authorities  as  regards  diseases  of  the  nervous 
system,  attribute  infantile  paralysis  to  disease  of  the  spine.  If  we 
accept  this  theory,  certainly  the  cause  of  infantile  paralysis  must 
in  many  instances  be  one  of  the  mildest  of  the  pathological  states 
of  the  nervous  centres,  since  there  are  so  many  cases  of  speedy 
recov.ery.  Spinal  congestion  is  held  by  Radclift'e  and  others  to  be 
this  pathological  state.  Still  there  are  certain  dififerences  in  the 
symptoms  of  spinal  congestion  as  it  ordinarily  occurs,  and  those 
present  in  many  cases  of  infantile  paralysis.  (See  *S'^.  Thomas's  IIosp. 
Bep.,  1870,  Barwell.) 

Another  theory  regards  infantile  paral3\sis  as  entirely  a  peripheral 
■disease,  resembling  in  many  instances,  both  as  regards  origin  and 
nature,  facial  paralj^sis  as  it  occurs  in  adults  from  protracted  ex- 
posure to  cold.  This  theory  is  thus  advocated  and  enunciated  by 
Mr.  Barwell:'  "I  do  not  see  how  at  all  we  can  escape  the  conclu- 
sion that  this  paralysis  is  purely  peripheral ;  a  malady  affecting  the 
ultimate  fibrillse  of  distribution  of  the  nerves  among  the  muscular 
elements."  ....  "Its  essence  lies  probably  in  some  subtile  de- 
rangement in  relationship  between  the  ultimate  muscular  and 
terminal  nerve-fi^bres,  perhaps  from  some  inflammatory,  perhaps 
from  some  chemical  or  nutrient  charge."  {Ibid.)  This  theory  may 
not  be  broad  enough  to  cover  those  cases  in  which  the  paralysis  is 
extensive,  as  when  both  lower  and  upper  extremities  are  involved, 
but  the  facts  observed  in  certain  cases  do  harmonize  better  with 
this  theory  than  with  that  of  a  central  origin,  and  I  would  ask 


ANATOMICAL    CnARACTERS.  435 

whether  in  some  instances,  at  least,  the  supposed  hypersesthesia 
which  attends  certain  cases  may  not  he  a  tenderness  due  to  the 
anatomical  chano-e  affectino;  the  terminal  nerve-fibres  alluded  to 
by  Barwell.  The  following  is  an  example  of  the  class  of  cases 
which  the  symptoms  indicate  have  a  peripheral  rather  than  central 
origin.  A.  K.,  German,  female,  aged  three  years  four  months, 
fleshy;  had  been  in  the  habit  of  sitting  on  the  ground  near  the 
house  and  on  the  door-sill.  On  July  2d,  1871,  she  had  a  sound 
sleep  in  the  afternoon,  having  been  entirely  well  previously,  and 
awoke  trembling  and  with  a  high  fever  at  3|  P.M.  At  8  P.M.,  the 
febrile  excitement  continuing,  general  clonic  convulsions  occurred, 
lasting  about  ten  minutes.  At  this  time  I  was  called  to  see  her, 
and  found  the  face  flushed,  surface  hot,  and  pulse  about  one  hun- 
•  dred  and  thirty.  Consciousness  returned  after  the  convulsion. 
The  intelligence  was  good,  tongue  moist  and  slightly  furred, 
bowels  rather  constipated,  and  the  urine  was  freely  passed.  The 
febrile  excitement  continued  two  days,  when  it  gradually  and  en- 
tirely abated,  but  before  it  ceased  paralysis  of  the  left  lower  ex- 
tremity was  observed.  ISTo  weight  at  first  could  be  sustained 
upon  this  limb,  and  it  hung  powerless  when  we  endeavored  to 
make  her  walk.  The  attempt  caused  her  to  cry,  as  if  in  pain,  and 
pressing  upon  the  thigh,  or  moving  it,  had  the  same  eflect.  The 
thigh  of  this  limb  did  appear  slightly  swollen  on  inspection,  but 
measurement  did  not  indicate  any  notable  enlargement.  The  dif- 
ference in  circumference  was  certainly  not  more  than  one-eighth  to 
one-fourth  of  an  inch.  There  was  no  appreciable  increase  of  heat 
in  the  thigh  over  the  general  temperature  of  the  body.  Sensibility 
remained  in  every  part  of  the  limb,  and  the  loss  of  power  was  not 
complete,  for  on  the  first  day,  as  soon  as  the  paralysis  was  ob- 
served, slight  and  imperfect  movements  could  be  produced  by  pinch- 
ing the  limb.  In  three  weeks  the  use  of  the  limb  was  fully  restored, 
by  mildly  stimulating  liniments,  and  simple  medicines  to  regulate 
the  bowels.  It  does  not  seem  improbable  that  in  the  future,  when 
the  true  pathology  of  this  disease  is  revealed,  we  shall  find  that 
there  are  two  forms  of  it,  one  having  a  centric  origin,  and  the 
other  an  eccentric,'cases  like  that  described  above  being  examples 
of  the  latter. 

Anatomical  Characters. — All  muscular  fibres  which  are  in  a 
state  of  disuse,  begin  in  a  few  weeks  to  atrophy,* and  undergo 
fatty  degeneration.  The  transverse  striae  in  the  primitive  muscu- 
lar fasciculus  gradually  disappear  and  are  replaced  by  granules  of 
fat,  and  later  still  by  small  oil  globules.     If  we  examine  with  the 


436  INFANTILE    PARALYSIS. 

microscope  the  fibres  from  a  muscle  wliicli  has  been  a  considerable 
time  paralyzed,  but  which  has  still  some  electric  contractility,  we 
will  find  in  places  the  striae  remaining,  but  numerous  opaque 
granules  of  a  fatty  nature  within  the  sarcolemma  wherever  the 
strise  are  absent,  and  in  other  places,  where  the  degeneration  is  most 
advanced,  oil  globules  occur,  always  small.  If  the  paralysis  is 
more  profound,  the  striae  have  all  disappeared.  At  a  later  stage, 
usually  after  some  years  in  cases  of  complete  and  incurable  paraly- 
sis, the  fatty  matter  may  be  to  a  considerable  extent  absorbed,  and 
the  fibrous  network  of  the  muscle  which  remains  presents  a  ten- 
donous  appearance.  There  is  a  great  difference,  however,  in  differ- 
ent cases,  as  regards  the  rapidity  with  which  these  changes  occur. 
Hammond  states  that  he  found  the  striae  remaining  in  two  cases 
after  the  lapse  of  more  than  four  years  of  decided  paralysis.  The 
nerves  of  the  paralyzed  part  also  undergo  atrophy. 

Little  can  be  said  that  is  positive  and  satisfactory  in  reference 
to  those  anatomical  changes,  whether  peripheral  or  centric,  which 
are  believed  to  cause  the  paralysis.  As  to  the  peripheral  cause, 
nothing  is  known  beyond  conjecture.  As  to  the  spinal  cause, 
several  autopsies  have  been  made  of  those,  dying  of  various  ages, 
who  were  paralyzed  from  infancy  or  childhood,  but  there  has  been 
no  uniformity  as  regards  the  condition  of  the  spinal  cord  or  its 
meninges,  and  an  examination  of  the  records  of  these  cases  con- 
vinces me  that  most  of  them  were  examples  of  spinal  disease, 
which  may  occur  at  any  age,  and  not  of  the  true  infantile  paralysis. 
Certain  diseases  of  the  spine  in  the  child  will  give  rise  to  paralysis 
as  they  do  in  the  adult,  but  we  should  not  regard  a  case  as  one  of 
infantile  paralysis  unless  it  has  the  clinical  history  of  that  disease. 
Thus,  writers  have  included  in  their  descrij^tion  of  the  lesions  of 
infantile  paralysis  a  case  reported  by  Berend,  in  which  the  cele- 
brated Recklinghausen  found  tubercles  in  the  spine.  Another 
case,  reported  by  Hutin,  presented  atrophy  of  the  lower  part  of  the 
spinal  cord,  but  the  paralysis,  unlike  that  which  we  are  describing, 
began  at  the  age  of  seven  years.  The  following  are  the  chief 
lesions  which  have  been  found  in  reported  cases :  sclerosis  of  spinal 
cord  (increase  of  its  connective  tissue,  and  more  or  less  atrophy  of 
the  nervous  substance  by  compression)  (Laborde  and  others),  cica- 
trix and  clot  (Hammond),  spinal  arachnitis,  with  thickening  of 
meninges  (Jaccoud),  atrophy  of  anterior  roots  of  spinal  nerves 
(Longet),  atrophy  of  lower  part  of  spinal  cord  (Hutin),  tubercles 
(Berend).  Finally,  Fleiss,  Adams,  and  Rilliet  and  Barthez  ex- 
amined cases  and  found  no  lesions  of  the  spine  or  spinal  meninges. 


DIAGNOSIS  —  PROGNOSIS.  437 

It  is  obvions  that  the  discovery  of  such  varied  lesions  in  the  spi- 
nal cords  of  those  who  have  been  paralytic  from  childhood  aids  1)iit 
little  in  elucidating  the  pathology  of  infantile  j^aralysis.  These 
observers  have  seen  the  lesions  in  spinal,  whether  they  have  or 
not  in  cases  of  true  infantile  paralysis,  but  it  is  to  be  observed  that, 
tubercles  excepted,  these  lesions  have  been  such  as  would  be  likely 
to  result  from  intense  and  continued  congestion  of  the  cord. 
Intense  congestion  may  cause  apoplexy,  and  congestion  long  con- 
tinued often  causes  a  subacute  and  chronic  inflammation,  among 
the  results  of  which,  in  case  of  the  spine,  would  probably  be 
sclerosis  and  atrophy  with  thickening  and  opacity  of  the  meninges. 
Or  may  not  the  atrophy  be  a  result  of  the  paralysis  just  as  atrophy 
of  the  nerves  occurs?  But  in  order  to  determine  the  exact  relation 
which  the  state  of  the  spine  sustains  to  infantile  paralysis,  accu- 
rate and  minute  examination  of  the  spinal  cord  is  required  in  those 
who  have  died  of  intercurrent  diseases  at  an  early  period  of  the 
paralysis.  The  researches  of  J.  Lockhart  Clarke  have  demonstrated 
that  the  microscope  may  aid  greatly  in  elucidating  the  cause  and 
nature  of  obscure  diseases  of  the  nervous  system.  It  has  already, 
in  his  hands,  revealed  structural  changes  of  the  cerebro-spinal  axis 
in  certain  affections,  which  without  its  aid  would  be  considered 
neuroses.  It  cannot  be  doubted  that  it  will  yet  contribute  much 
to  a  better  understanding  of  this  disease. 

Diagnosis. — This  is  easy  as  soon  as  the  attention  of  the  j^hysi- 
cian  is  directed  to  the  state  of  the  limbs.  In  a  large  proportion  of 
cases  the  mother  or  nurse  first  observes  the  paralysis,  and  calls  the 
attention  of  the  physician  to  it.  A  knowledge  and  recollection  of 
the  facts  in  relation  to  infantile  paralysis  should  lead  the  physician 
to  examine  the  state  of  the  limbs  in  all  cases  of  2:reat  febrile 
excitement  in  young  children,  occurring  without  apparent  cause. 

Prognosis. — It  may  be  confidently  predicted,  if  the  child  is  seen 
early,  and  correctly  treated,  that  the  paralysis  will  diminish,  if  it 
cannot  be  entirely  cured.  .If  the  paralysis  has  continued  a  con- 
siderable time,  and  there  is  no  electric  contractility  of  the  muscles, 
there  is  poor  prospect  of  any  improvement.  The  induced  current 
will  fail,  sometimes,  to  cause  muscular  contraction,  when  the 
direct  current  may  produce  it ;  but  if  there  is  no  response  to  the 
direct  current,  there  is  no  therapeutic  agent  which  can  restore  the 
use  of  the  limb. 

In  cases  seen  soon  after  the  paralysis  commences,  and  before  the 
stage  of  atrophy,  the  prognosis  is  most  favorable,  when  there  is 
still  slight  voluntary  motion,  and  improvement  commences  early. 


438  INFANTILE    PARALYSIS. 

In  most  instances,  even  when  the  paralysis  has  been  mild,  and 
of  comparatively  short  dnration,  the  limb,  although  its  motion  is 
full}"  restored,  is  for  a  long  time  weaker  than  the  limb  on  the 
opposite  side. 

Treatment. — A  physician  called  at  the  commencement  of  the 
paralysis  should  endeavor  to  remove  every  cause  which  might 
increase  the  irritability  of  the  nervous  system.  It  is  proper  to 
scarify  the  gums,  if  much  swollen  and  tender  from  dentition,  the 
bowels  should  be  kept  regular,  worms,  if  present,  expelled  by 
appropriate  medicines,  and  the  diet  be  plain  and  unirritating. 
As  the  cause  of  the  paralysis  is  in  the  commencement  still  opera- 
tive, measures  are  appropriate  which  are  calculated  to  remove  it. 

Local  treatment  is  very  important  at  all  periods  of  the  paralysis. 
In  the  first  days  a  tepid  hip-bath  employed  daily,  with  brisk  fric- 
tion of  the  surface,  has  a  salutary  effect.  Stimulating  embrocations 
along  the  spine,  and  upon  the  paralyzed  limb,  are  appropriate  also 
at  an  early  date.  Possibly,  if  there  is  a  strong  ^jrobability  of 
spinal  congestion,  cold -applied  along  the  spine,  by  ether  spray  or 
otherwise,  might  be  useful,  but  I  am  not  aware  that  it  has  been 
employed  in  this  disease.  If  the  paralysis  appear  to  have  a  central 
origin,  ergot,  the  bromide  and  iodide  of  potassium,  which  may  be 
administered  variously  combined,  or  singly,  are  the  appropriate 
remedies  for  the  first  twelve  or  fourteen  days.  Administered  every 
three  or  four  hours  in  proper  dose,  they  are  the  most  eiiectual  of 
all  internal  remedies  for  diminishing  spinal  congestion,  and  pre- 
venting efiJ'usion,  and  permanent  structural  change  in  the  cord. 

If  the  paralysis  continue,  or  is  not  progressively  diminishing, 
we  should  not  delay  more  than  two  Aveeks  from  the  commencement 
of  the  disease  before  employing  appropriate  measures  to  restore 
the  use  of  the  limbs,  and  prevent  atrophy  of  the  muscles.  The 
expectant  plan  of  treatment  which  is  proper  in  many  diseases  of 
children  is  unsuited  to  this.  Muscular  atrophy  may  commence  in 
three  weeks,  and  the  further  it  has  advanced,  the  more  difiicult 
and  tedious  will  be  the  cure.  Therefore,  by  the  close  of  the  second 
week  if  the  paralysis  continue,  or  is  not  rapidly  disappearing,  iron 
as  a  tonic  with  strychnia  should  be  prescribed.  There  is  j^robably 
no  better  formula  for  the  exhibition  of  these  agents  than  the  fol- 
lowing from  Prof.  Hammond: — 

^.  Strycli.  sulpliat.  gr.  j  ; 
Fcrri  pyropbosphat.  .^ss ; 
Acidi  phosphorici  dilut.  §ss; 
Syr.  zingib.  §iijss.     Misce. 


TREATMENT.  439 

One-third  of  a  teaspoonful,  or  one-ninetieth  of  a  grain  of  strychnia, 
is  sufficient  for  a  cliild  of  two  years,  administered  three  times 
daily.  Ilillier,  Barwell,  and  otliers  have  employed  subcutaneous 
injections  of  stryclmia,  with,  it  is  stated,  a  good  result.  While  in 
the  first  and  second  weeks  the  child  has  been  allowed  to  remain 
quiet,  he  should  now  be  encouraged  to  use  his  limbs.  Frequent 
muscular  contraction  must,  if  possible,  be  produced,  and  the 
voluntary  movements,  when  not  totally  lost,  aid  greatly  in  pro- 
moting the  nutrition  of  the  muscles  and  restoring  their  function. 
Immersing  the  limb  for  half  an  hour  in  water  at  a  temperature 
of  110  or  115  degrees,  rubbing  the  limb  with  a  coarse  towel,  and 
kneading  the  muscles,  aid  also  in  restoring  nutrition  and  tone  to 
them. 

But,  fortunately,  w^e  have  an  invaluable  agent  in  the  subtle 
electrical  fluid,  which  can  be  made  to  penetrate  the  muscles  and 
cause  their  contraction  when  every  other  measure  has  failed.  The 
induced  current  should  be  employed  upon  the  limb  every  day,  or 
second  day,  if  it  cause  the  muscles  to  act,  but  if  the  loss  of  power 
is  of  long  standing,  or  complete,  so  that  the  induced  current  is  not 
sufficiently  powerful,  the  direct  current  should  be  used  instead.  It 
is  not  regarded  as  important  which  way  the  current  p)asses,  pro- 
vided the  muscles  contract. 

In  a  large  proportion  of  cases  a  cure  cannot  be  effected  until  the 
lapse  of  several  months,  so  that  the  patience  of  the  physician  and 
friends  may  be  put  to  the  test;  but  if  muscular  atrophy  can  be 
prevented,  and  the  limb  kept  at  near  the  normal  temperature,  this 
mode  of  treatment  will  ordinarily  in  the  end  be  successful.  The 
primary  affection  which  caused  the  paralysis  will,  with  some 
exceptions,  abate  of  itself,  so  that  the  state  of  the  muscles  and  their 
nervous  supply  demand  the  whole  attention.  Observations  show 
that  by  treatment  perseveringly  employed,  fatty  degeneration  of 
the  muscular  fibres  can  not  only  be  arrested,  but  the  fat  which  has 
already  been  deposited  within  the  sarcolemma  may  be  absorbed, 
and  the  muscular  strise  restored.  In  those  cases  in  which  it  has 
been  necessary  to  employ  the  direct  current,  the  induced  should  be 
employed,  whenever  by  the  improvement  of  the  case  it  is  found 
sufficiently  powerful. 


440  FACIAL    PAEALYSIS. 


CHAPTER  XYI. 

FACIAL  PAEALYSIS. 

Causes. — Facial  paralysis,  in  the  new-born,  commonly  occurs 
from  pressure  of  the  blade  of  the  forceps  upon  the  portio  dura,  at 
a  point  external  to  the  stvlo-mastoid  foramen.  It  mav  also  occur  in 
children  of  any  age,  as  it  is  known  to  in  the  adult,  from  exposure 
of  the  face  to  a  cold  wind.  The  pressure  of  a  tumor  upon  some 
part  of  the  portio  dura,  or  even  of  the  fist  of  the  child  placed  under 
the  face  during  sleep,  may  cause  it.  It  may  also  result  from  disease 
of  the  temporal  bone,  producing  pressure  on  the  nerve,  as  caries, 
periostitis,  suppuration,  or  hemorrhage  into  the  aquteductus 
Fallopii,  and  also  from  intra-cranial  disease  afiecting  the  pons 
Varolii  or  the  medulla  oblongata. 

Symptoms. — The  portio  dura,  which  is  a  nerve  of  motion,  supplies 
the  muscles  of  the  face,  and  therefore  its  loss  of  function  is  at  once 
manifest  in  distortion  of  the  features.  The  eye  of  the  affected  side 
remains  open  in  consequence  of  paralysis  of  the  orbicularis  palpe- 
brarum, the  upper  lid  being  raised  by  the  levator  muscle,  which  is 
not  paralyzed,  as  its  nerve  is  derived  from  the  third  pair.  From 
the  inability  to  wink,  the  eye  becomes  irritated  by  dust  and  con- 
stant exposure,  and,  in  children  old  enough  to  have  an  abundant 
lachrymal  secretion,  the  tears  are  apt  to  flow  over  the  cheek.  On 
account  of  the  paralyzed  and  relaxed  state  of  the  facial  muscles 
the  mouth  is  drawn  towards  the  healthy  side,  while  the  affected 
side  presents  a  swollen  appearance.  Movement  of  the  eyebrow 
and  of  the  anterior  portion  of  the  scalp  on  the  paralyzed  side  is 
also  impossible,  since  the  occipito-frontalis  and  corrugator  supercilii 
are  supplied  by  the  portio  dura.  If  the  cause  of  the  disease  is 
located  above  the  origin  of  the  chorda  tympani,  the  flow  of  saliva, 
and  consequently  the  taste,  on  the  affected  side  are  impaired.  If  the 
injury  is  posterior  to  the  gangliform  enlargement,  those  symptoms 
are  superadded  which  are  due  to  paralysis  of  the  petrosal  nerves. 

Prognosis. — This  depends  on  the  cause.  K  the  cause  is  peri- 
pheral, as  from  the  pressure  of  the  forceps  or  from  cold,  the  prog- 
nosis is  favorable.     In  cases  of  deep-seated  lesion,  unless  syphilitic, 


PARALYSIS  WITH  APPARENT  HYPERTROPHY.    441 

the  prognosis  is  usually  unfavorable.    A  sjj»liilitic  lesion  can  often 
be  removed  by  appropriate  remedies  and  the  paralysis  cured. 

Treatment. — In  the  paralysis  of  the  new-born,  from  pressure  of 
the  forceps,  all  that  is  required  is  occasional  rubbing  or  gentle 
kneading  over  the  affected  muscles.  In  those  who  are  older,  the 
nature  of  the  cause,  so  far  as  ascertained,  must  determine  the 
treatment.  If  there  are  glandular  swellings,  and  discharge  from 
the  ear  from  scrofula,  cod-liver  oil  and  the  syrup  of  the  iodide  of 
iron  are  required  internally,  with  appropriate  external  treatment 
of  the  glands  and  ear.  If  sy^jhilis  is  the  cause,  mercurials  and 
the  iodide  of  potassium  should  be  employed.  If  the  patient  does 
not  begin  soon  to  improve,  the  treatment  recommended  for  infan- 
tile paralysis,  modified  somewhat  on  account  of  the  difference  in 
location,  is  appropriate.  Iron  and  strychnia  may  be  administered 
internally;  friction,  kneading,  hot  applications,  and  the  electric 
current  employed.  The  current  should  have  only  moderate  inten- 
sity, for  a  high  degree  of  it  might  injure  the  vision.  It  should  be 
applied  every  second  day,  with  one  pole  over  the  mastoid  foramen, 
and  the  other  moved  slowly  over  the  muscles. 

PARALYSIS  WITH  APPARENT  HYPERTROPHY. 

This  is  a  rare  disease.  It  was  first  described  by  Duchenne  in 
1861,  and  since  the  attention  of  the  profession  was  directed  to  it, 
cases  have  been  observed  on  the  continent,  in  Great  Britain,  and 
this  country.  Though  our  acquaintance  with  this  disease  is  so 
recent,  it  has  been  fullv  and  accuratelv  described  bv  various  writers 
in  our  language.  The  Transactions  of  the  Load.  Path.  Soc.  for  1868 
contain  a  translated  pa]:>er  relating  to  this  disease,  communicated  by 
M.  Duchenne,  with  photographic  views,  remarks  by  Lockhart  Clarke, 
and  also  the  histories  of  two  cases  occurring:  in  London,  and  ex- 
hibited  to  the  society  by  Adams  and  Hillier.  In  this  country  an 
elaborate  paper  has  appeared  on  this  form  of  paralysis,  from  the  pen 
of  Dr.  Webber,  of  Boston,  who  succeeded  in  collecting  the  records 
of  forty-one  cases.  {Bost.  Jled.  and  Surg.  Journ.,  Xov.  17,  1870.) 
Meigs,  and  Pepper,  and  Prof.  Hammond  have  described  this  dis- 
ease in  their  treatises,  and  the  following  wood-cut  represents  a  case 
which  occurred  in  the  practice  of  the  last  gentleman,  and  which 
conveys  a  good  idea  of  the  appearance  of  one  affected  with  this 
paralysis.  In  certain  cases,  however,  as  in  one  figured  by  Duchenne, 
there  are  still  greater  curvatures  and  enlargement  than  are  repre- 
sented in  this  wood-cut. 


442 


PARALYSIS  WITH  APPARENT  HYPERTROPHY. 


Symptoms. — This  disease  in  a  considerable  proportion  of  cases 
begins  in  infancy,  and  attention  is  first  directed  to  it  when  the 
patient  attains  the  age  at  which  it  begins  to  stand  and  walk,  which 
is  not  ordinarily  till  some  months  later  than  the  usual  time.  In 
eleven  of  the  cases  tabulated  by  Webber  in  which  the  disease  had 
an  early  commencement,  walking  was  impossible  till  between  the  ages 
of  seventeen  months  and  three  years,  and  then  it  was  in  a  clumsy 
manner.  The  gait,  which  is  unsteady  and  waddling,  has  been 
compared  to  that  of  a  duck.  The  child  stands  with  the  legs  wide 
apart,  and,  from  the  unsteadiness  of  the  gait,  frequently  stumbles 
and  falls.  It  is  admitted  by  those  who  have  had  the  best  oppor- 
tunities to  study  the  disease,  that  the  muscular  weakness  com- 
mences before  there  is  any  appreciable  enlargement.     Therefore,  if 

the  disease  begin  after  the  child  has  walked, 
the  peculiar  clumsy  gait  attracts  attention 
before  there  is  anything  in  the  appearance 
to  indicate  the  nature  of  the  disease. 

The  enlargement  ordinarily  occurs  first  in 
the  calf  of  one  leg,  then  in  the  opposite  calf, 
and  later  in  the  thighs  and  hips.  In  l^ie- 
meyer's  case,  the  muscles  of  the  gluteal  re- 
gion were  first  afl'ected.  When  the  disease 
is  fully  developed,  the  spine  is  so  incurvated 
that  a  perpendicular  line  from  the  most  poste- 
rior of  the  spinous  processes  falls  behind  the 
sacrum.  Duchenne  attributes  the  curvatures 
to  weakness  of  the  erector  muscles  of  the 
spine. 

As  the  disease  advances,  the  muscles  of 
the  trunk  and  upper  extremities  become  in- 
volved, though  the  enlargement  is  less  rapid 
and  less  in  degree  in  these  muscles  than  in 
those  of  the  lower  extremities.  Finally,  in 
advanced  and  severe  cases  walking  is  impos- 
sible, and  the  patient  is  obliged  to  remain  in 
a  reclining  posture.  Movements  are  now 
often  painful,  and  distortions  may  occur  on 
account  of  the  loss  of  antagonism  in  the 
muscles.  Experiments  show  that  in  some 
cases  the  electric  contractility  of  the  muscles  remains  nearly 
normal,  while  in  other  cases  it  is  impaired.  The  skin  retains  its 
normal  sensibility.     The  intellectual  faculties  are  usually  more  or 


ANATOMICAL    CHARACTERS.  443 

less  impaired,  cspcciall}^  in  tliose  cases  which  begin  in  early  infancy. 
This  disense  is  chronic,  rarely  terminating  till  after  five  or  six 
years,  and  in  many  not  till  a  considei'ably  longer  time. 

Anatomical  Characters. — There  have  been  so  few  post-mortem 
examinations  of  those  who  died  having  this  disease,  that  it  is 
still  uncertain  whether  there  is  any  centric  lesion.  Cohnheim 
examined  the  spinal  cord  in  one  case,  and  could  find  nothing  ab- 
normal. Recently,  Mr.  Kesteven  has  examined  the  brain  and 
spinal  cord  from  a  case,  and  found  dilatation  of  the  perivascular 
canals,  both  in  the  brain  and  spinal  cord,  and  also  spots  of 
granular  degeneration  chiefly  in  the  white  substance,  "caused  by 
loss  of  cerebral  tissue  replaced  by  morbid  matter."  (Journ.  of- 
Mental  Sci.,  Jan.  1871).  As  this  child  was  imbecile,  it  is  not 
improbable  that  these  lesions  were  connected  with  the  mental 
state,  and  not  the  muscular  disease.  It  is  probable,  from  the  facts 
which  have  been  observed,  that  the  lesions  of  this  paralysis  are 
eccentric,  or  if  central  lesions  occur,  that  they  are  consecutive  and 
subordinate.  As  the  disease  consists  in  a  sclerosis,  or  hyperplasia  of 
the  connective  tissue  surrounding  the  muscles,  there  is  sufficient 
explanation  of  the  paralysis  in  the  impairment  of  function,  and 
atrophy  of  muscular  fibres,  which  such  a  hyperplasia  would  be  likely 
to  produce  by  its  mechanical  effect.  Analogous  examples  will  occur 
to  the  reader,  of  impairment  or  loss  of  function  of  internal  organs, 
from  hyperplasia  of  their  connective  tissue.  Still,  in  those  cases  of 
this  disease  which  have  been  observed  from  their  commencement, 
weakness  of  the  muscles  has  appeared  before  there  was  that 
degree  of  hyperplasia  which  produced  any  decided  enlargement 
of  the  affected  part. 

The  disuse  of  the  muscles  increases  their  atrophy,  consequently 
in  cases  of  this  disease  which  have  continued  a  considerable  time, 
and  are  fully  developed,  the  microscope  shows  not  only  atrophy  of 
those  muscles  whose  connective  tissue  have  undergone  hyperplasia, 
but  also  to  a  certain  extent  of  those  which  are  adjacent,  and  have 
a  similar  function,  but  are  not  the  seat  of  the  disease.  The  aiFected 
muscles  present  a  pale  yellowish  hue,  resembling,  says  ISTiemeyer, 
the  appearance  of  lipoma.  Examining  by  the  microscope,  we  find 
in  addition  to  a  large  increase  in  the  fibrous  tissue,  and  atrophy 
and  in  some  places  disappearance  of  the  muscular  element,  more  or 
less  fatty  matter,  granular  and  globular,  occu23ying  the  interstices. 
Mr.  Kesteven  describes  as  follows  the  appearance  of  the  muscles  in 
the  case  which  he  examined :  "  The  muscular  substance  is  pale, 
almost  white,  and  very  greasy.     The  superabundance  of  fat  is 


41-i    PARALYSIS  WITH  APPARENT  HYPERTROPHY. 

evident  to  the  naked  eye.  The  muscular  fibres  present  the  ordi- 
nary striation,  but  less  distinctly  than  usual.  The  ultimate  fibres 
are  pale,  and  separated  by  a  large  increase  of  areolar  and  fibrous 
tissue. 

Causes. — These  are  obscure.  Duchenne,  in  cases  which  he  ex- 
amined, could  find  no  evidence  of  inherited  taint  or  predisposition. 
^Nevertheless,  in  several  of  the  recorded  cases  one  or  more  brothers 
or  sisters  were  similarly  affected,  showing  some  latent  cause  in  the 
family.  In  one  case  observed  by  Duchenne  the  disease  appeared 
to  be  congenital,  for  at  birth  the  limbs  were  unusually  large,  and 
the  patient  when  he  came  under  observation  had  never  been  able 
to  walk.  'No  relation  has  been  observed  between  syphilis,  scrofula, 
or  other  diathetic  diseases,  and  this  form  of  paralysis.  Boys  are 
more  apt  to  be  affected  than  girls.  Of  the  cases  embraced  in  the 
statistics  of  Dr.  "Webber,  thirty-eight  were  boys  and  seven  girls. 

Prognosis. — This  disease  is  in  most  instances  progressive,  termi- 
nating fatally  after  a  variable  period.  It  is  in  its  nature  chronic, 
rarely  ending  in  less  than  five  or  six  years,  and  a  considerable 
proportion  living  longer,  some  even  attaining  adult  age.  The 
paralj^sis  may  be  stationary  for  a  time,  but  afterwards  continue  to 
increase.  Duchenne  has  reported  one  case  of  recovery.  In  two  or 
three  other  instances  patients  appeared  to  improve  somewhat  under 
treatment,  but  the  writers  admit  they  may  have  become  worse 
afterwards.  Death  is  apt  to  occur,  not  directly  from  the  paralysis, 
but  from  some  intercurrent  disease,  especially  of  the  lungs. 

Treatment. — The  treatment  thus  far  employed*  has  been  chiefly 
local,  consisting  in  the  use  of  electricity,  and  kneading  or  sham- 
pooing over  the  affected  muscles.  Both  the  primary  and  induced 
electrical  currents  have  been  employed,  but,  unfortunately,  with- 
out any  appreciable  benefit  in  most  cases.  Benedikt,  who  claims  a 
better  result  from  electrization  than  any  other  observer,  applied 
the  copper  pole  over  the  lower  cervical  ganglion  and  the  zinc  jDole 
along  the  side  of  the  lumbar  vertebrae  by  means  of  a  broad 
metallic  plate. 


SECTION"  11. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


CHAP  TEH   I. 

CORYZA, 


The  term  coryza  is  a2:)plied  to  inflammation  of  the  Sclnieiderian 
membrane.  It  is  acnte  or  chronic.  The  acute  form  is  primary  or 
secondary.  Acute  primary  coryza  is  common  in  infancy  and  child- 
hood. Its  usual  cause  is  exposure  to  currents  of  air,  to  cold,  and 
especially  to  sudden  changes  of  temperature  from  warm  to  cold. 
The  cause  is  the  same  as  that  in  the  ordinary  forms  of  bronchitis. 
These  two  diseases  frequently  indeed  coexist,  occurring  from  the 
same  exposure.  The  inflammation  in  such  cases  commences  upon 
the  Schneiderian  membrane,  immediately  upon  the  operation  of 
the  cause,  and  soon  after  extends  to  the  bronchial  tubes.  Acute 
coryza  may  also  be  produced  by  the  inhalation  of  irritating  vapors, 
hot  air,  or  dust,  and  also  by  the  presence  of  a  foreign  body,  as  a 
button  or  bean,  in  the  nostril. 

Secondary  coryza  is  commonly  due  to  a  specific  cause.  The 
diseases  in  connection  with  which  it  occurs  are  hooping-cough, 
measles,  scarlet  fever,  diphtheria,  and  constitutional  syphilis.  In 
the  infant,  coryza  is  one  of  the  first  manifestations  of  hereditary 
syphilitic  taint. 

Acute  primary  coryza  ordinarily  abates  in  from  one  to  two 
weeks.  The  secondary  form  gradually  declines,  in  most  cases, 
when  the  primary  affection  on  which  it  depends  is  cured.  Syphi- 
litic coryza  is  more  protracted  than  the  primary  form,  or  than  that 
accompanying  the  eruptive  fevers.  Some  children  are  so  liable  to 
coryza  that  it  occurs  whenever  they  take  cold.  Occasionally  it  is 
so  frequently  renewed  in  the  winter  months,  that  it  resembles  the 
chronic  form  of  the  disease. 

Chronic  coryza  is  commonly  dependent  on  a  dyscrasia.     It  cor- 


446  CORYZA. 

responds  with  chronic  inflammation  of  the  external  ear,  and  otor- 
rhoea  is  not  infrequent  in  connection  with  it.  The  dyscrasia  is 
indicated  hy  pallor,  flabbiness  of  the  flesh,  and  liability  to  glandu- 
lar swellings.  Chronic  coryza  may  also  occur  in  those  who  have 
good  general  health,  as  the  result  of  an  acute  attack.  Many  a 
case  dates  back  to  one  of  the  exanthematic  fevers,  the  local 
affection  continuing  after  the  general  health  is  restored.  Rarely 
chronic  coryza  comes  on  gradually  and  without  appreciable  cause. 

Anatomical  Characters. — The  alterations  which  the  nasal 
mucous  membrane  undergoes  when  inflamed,  vary  considerably  in 
different  cases.  In  the  simplest  and  most  common  form  of  coryza, 
this  membrane  is  sometimes  in  patches,  sometimes  generally  red- 
dened, thickened,  and  softened.  Its  papillse  are  prominent,  produc- 
ing an  inequality  of  the  surface.  Ulcerations  are  not  common  in 
simple  acute  coryza,  but  they  sometimes  occur  in  the  chronic  form. 

In  diphtheria,  and  not  infrequently  in  scarlet  fever  and  variola, 
the  corj'Za  is  pseudo-membranous,  and  when  it  presents  this  form 
it  is  associated  with  pseudo-membranous  angina  or  laryngitis.  A 
case  of  pseudo-membranous  coryza  occurring  in  measles  is  related 
by  M.  Guibert.  The  patient  was  a  rachitic  boy,  three  and  a  half 
years  old.  The  pseudo-membrane,  in  severe  cases,  may  cover 
almost  the  entire  surface  of  the  nostrils,  but  ordinarily  it  occurs  in 
patches. 

Symptoms. — The  constitutional  symptoms  are  mild  or  severe, 
according  to  the  gravity  of  the  inflammation.  If  the  coryza  is 
acute  and  pretty  general,  there  is  febrile  movement,  with  thirst 
and  loss  of  appetite.  Frontal  headache  is  common,  from  the 
proximity  of  the  inflammation  to  the  head,  or  its  extension  to  the 
frontal  sinuses.  Sneezing  is  the  first  symptom  in  many  cases  of 
acute  corj'za.  As  the  inflamed  membrane  swells,  more  or  less  ob- 
struction occurs  to  respiration.  The  breathing  is  noisy,  especially 
during  sleep,  and,  in  severe  cases,  the  patient  is  compelled  to 
breathe  mostly  through  the  mouth.  If  there  is  much  obstruction 
to  respiration,  the  suffering  of  the  patient  is  considerable,  from  the 
sensation  of  fulness  in  the  nostrils,  the  headache,  and  the  muscular 
effort  required  in  each  respiratory  act. 

In  the  conmicncement  of  coryza  the  patient  experiences  a  sensa- 
tion of  dryness  in  the  nostrils,  which  is  soon  succeeded  by  a  thin  dis- 
charge of  a  serous  appearance.  In  the  course  of  a  few  hours  the 
secretion  becomes  thicker.  It  is  muco-purulent,  and  remains  such 
till  the  disease  begins  to  decline.     Inspissated  mucus  and  crusts 


PROGNOSIS  — TREATMENT.  447 

are  apt  to  collect  within  tlie  nostrils  and  around  tlicir  orifice  in 
chronic  coryza,  and  sometimes  also  in  the  acute  disease,  if  the  dis- 
charge is  not  abundant.  These  crusts  increase  the  difticulty  of 
breathing.  Often  the  acridity  of  the  discharge  is  such  that  the 
skin  of  the  upper  lip,  and  around  the  nostrils,  is  excoriated. 

Prognosis, — Simple,  uncomplicated  coryza  rarely  terminates  fa- 
tally. It  is  only  dangerous  in  young  nursing  infants,  in  whom  it 
may  seriously  interfere  with  lactation.  Coryza,  accompanying  the 
eruptive  fevers,  although  it  may  increase  the  suffering,  does  not 
materially  increase  the  danger.  '  Syphilitic  coryza  subsides  when 
the  system  is  sufficiently  affected  by  anti-syphilitic  remedies. 
Chronic  coryza  is  sometimes  very  obstinate.  It  may  continue  for 
months  or  years,  giving  rise  to  a  constant,  but  often  not  abundant, 
discharge. 

Treatment. — Common  mild  attacks  of  coryza  require  little 
treatment.  The  bowels  should  be  kept  open,  the  feet  soaked  in 
mustard-water,  and  the  body  should  be  warmly  clothed.  Some 
benefit  may  be  derived  from  friction  with  camphorated  oil  over 
the  nose.  If  coryza  commence  with  symptoms  which  indicate  a 
pretty  severe  attack,  and  there  are  evidences  of  extension  of  the 
disease  towards  the  bronchial  tubes,  an  emetic  of  syrup  of  ipeca- 
cuanha, given  at  an  early  period,  moderates  the  severity  of  the 
inflammation  and  may  prevent  the  occurrence  of  bronchitis. 
Afterwards  a  simjjle  diaphoretic  mixture,  as  the  following,  should 
be  given : — 

R.  Syrupi  ipecacnanhfe  ,"ij  ; 
Spirit,  fpthei-.  nitr.  5j  ; 
Syrupi  simplicis  gij.     Misce. 

One  teaspoonful  every  three  hours  to  a  child  of  six  months.  In 
place  of  sweet  spirits  of  nitre,  acetatt^  of  potash  may  be  employed 
in  the  dose  of  one  to  two  grains  for  infants  ;  and  if  there  is  decided 
febrile  reaction,  from  half  a  minim  to  two  minims,  according  to 
the  age,  of  tincture  of  digitalis,  should  be  added  to  each  dose. 

In  pseudo-membranous  coryza  the  main  treatment  must  be  di- 
rected to  the  accompanying  laryngitis,  if,  as  is  usual,  the  latter 
affection  is  present,  since  the  coryza  is  much  less  dangerous  than 
the  other  inflammation.  Still,  if  it  cause  any  obstruction  to  the 
respiration  and  increase  the  suffering  of  the  patient,  it  requires 
attention.  The  frequent  injection  into  the  nostrils  of  a  solution  of 
chlorat'e  of  potash  in  water,  with  five  or  six  drops  of  carbolic  acid 
to  each  ounce,  exerts  a  beneficial  effect  upon  the  inflammation,  and 
aids  in  removing  the  accumulation  of  fibrin,  mucus,  and  pus.     It 


44:8  CORYZA. 

slioiild  be  employed  several  times  in  tlie  course  of  tlie  day.  Alum 
injections,  four  or  five  grains  to  the  ounce  of  water,  are  also  useful 
in  a  certain  proportion  of  cases ;  or  a  solution  of  one  of  the  mineral 
astringents  may  be  employed,  as  liquor  ferri  subsulphatis,  acetate 
of  lead,  sulphate  of  copper,  or  nitrate  of  silver.  The  bromine  solu- 
tion described  in  our  remarks  on  the  treatment  of  croup  will  also 
be  found  useful,  injected  into  the  nostrils. 

In  most  cases  of  pseudo-membranous  coryza  constitutional  mea-' 
sures  are  required,  on  account  of  the  disease  with  which  it  is 
associated.  In  cases  of  acute  simple  coryza,  and  in  the  pseudo- 
membranous, inhalation,  through  the  nostrils,  of  the  vapor  of  hot 
water  or  of  steam  from  hops  often  gives  relief ;  occasionally  it  is 
an  important  part  of  the  treatment.  Syphilitic  coryza  requires 
those  measures  which  are  appropriate  for  constitutional  syphilis. 

Chronic  coryza,  dependent  on  a  dyscrasia,  is  best  treated  by 
tonic  and  alterative  remedies.  The  various  ferruginous  prepara- 
tions, as  wine  of  iron,  tincture  of  the  chloride  of  iron,  iron  lozenges, 
may  be  advantageously  employed,  or  the  vegetable  tonics.  If 
there  are  pallor,  softness  of  flesh,  and  especially  glandular  swellings, 
indicating  a  scrofulous  state  of  system,  the  syrup  of  the  iodide  of 
iron  is  useful,  with  or  without  cod-liver  oil.  The  diet  should  be 
nutritious,  and  the  hygienic  measures  such  as  invigorate  the  gene- 
ral health.  Injections  into  the  nostrils  of  a  solution  of  alum,  five 
grains  to  the  ounce,  of  nitrate  of  silver,  three  to  five  grains  to  the 
ounce,  or  of  one  of  the  other  mineral  astringents,  are  sometimes 
useful  in  connection  with  constitutional  measures.  An  excellent 
formula  in  chronic  coryza,  for  application  to  parts  which  can  be 
reached  by  a  camel's-hair  pencil,  is  the  following : — 

I^.  Ung.  hydrarg.  ammoniat., 
Axungife,  equal  parts.     Misce. 

At  the  Out-door  Department  of  Bellevue,  this  ointment,  or  the 
citrine  diluted  in  the  same  proportion,  has  proved  more  eflectual 
in  this  disease  than  any  other  local  remedy.  It  should  be  applied 
three  times  daily,  as  far  within  the  nostrils  as  possible. 

Dr.  J.  F.  Meigs,  of  Philadelphia,  recommends  the  following 
ointment  in  chronic  coryza,  to  be  applied  at  night,  after  the  use  of 
injections  through  the  day: — 

I^.  Unguenti  liydrargyri  nitratis  3s3  ; 
Extract!  belladonua?  gr.  x ; 
Axungiae  §ss.     Misce. 

"It  should  be  applied,"  says  Dr.  Meigs,  "after  being  completely 


SIMPLE    LARYNGITIS.  449 

Boftened  by  a  gentle  licat,  on  a  camel's-hair  pencil,  care  being  taken 
to  ap[ily  it  tlioronglily  to  the  surface  of  the  mucous  membrane 
itself,  and  not  merely  to  the  outside  of  tlic  hardened  scabs." 


C HATTER  II. 

SIMPLE  LARYNGITIS. 

Simple  acute  laryngitis  occurs  at  all  ages,  but  it  is  so  common 
in  infancy  and  childhood  that  it  is  proper  to  treat  of  it  in  a  work 
relating  to  the  diseases  of  these  periods.  Like  other  inflammatory 
affections  of  the  air-passage,  it  is  most  common  in  the  cold  months 
or  when  the  weather  is  changeable.  Its  usual  cause  is,  therefore, 
exposure  to  cold.  Crying,  protracted  and  violent, and  the  inhalation 
of  acrid  vapors,  are  occasionally  causes.  Simple  or  erythematous 
laryngitis  also  occurs  in  connection  with  certain  other  diseases, 
among  which  may  be  mentioned  measles,  scarlatina,  and  variola. 
In  most  cases  of  bronchitis,  also,  and  in  many  of  pneumonia,  there 
is  laryngitis,  though  its  symptoms  are,  in  great  measure,  obscured 
by  those  of  the  graver  affection.  More  or  less  laryngitis  is  com- 
mon in  pharyngitis,  due  to  extension  of  the  inflammation. 

Symptoms. — Ordinarily,  in  cases  of  simple  or  erythematous  laryn- 
gitis, produced  by  the  impression  of  cold,  coryza  precedes  and  ac- 
companies the  attack.  The  first  symptom  is  chilliness,  followed 
by  sneezing,  and  a  discharge  from  the  nostrils  due  to  the  coryza. 
The  commencement  of  laryngitis  is  indicated  by  hoarseness,  which 
is  apparent  when  the  child  cries,  or,  if  old  enough,  when  he 
attempts  to  speak.  There  is,  in  severe  cases,  often  complete  loss 
of  voice,  so  that  the  child  cannot  speak  above  a  whisper.  I  have 
noticed  this  most  frequently  in  the  laryngitis  which  accompanies 
measles.  Cough  is  also  a  common  symptom  of  this  disease.  It  is 
at  first  dry  and  husky,  becoming  loose  in  the  course  of  a  few  days. 
But  expectoration  is  scanty,  except  when  the  inflammation  has 
extended  to  the  trachea  and  bronchial  tubes. 

This  disease  is  often  accompanied  by  soreness  of  the  throat,  no- 
ticed in  the  act  of  coughing  or  when  the  larynx  is  pressed  with  the 
finger.  In  simple  laryngitis,  when  uncomplicated,  the  respiration 
remains  nearly  natural  and  the  pulse  is  but  little  accelerated.  In 
mild  cases  the  nature  of  the  disease  is  often  not  apparent  as  long 
29 


'0 

450  SIMPLE    LARYNGITIS. 

as  the  cliild  remains  quiet,  in  consequence  of  the  absence  of  symp- 
toms, but  the  character  of  the  voice,  when  he  cries  or  speaks,  or  of 
the  cough,  reveals  at  once  the  nature  of  the  affection. 

Simple  acute  laryngitis  subsides  in  from  one  to  two  weeks.  Oc- 
casionally it  lasts  three  or  four  weeks  before  the  symptoms  entirely 
disappear.     Death,  which  is  rare,  is  due  to  some  complication. 

Chronic  laryngitis  is  much  less  frequent  than  the  acute  form. 
Its  anatomical  characters  are  similar  to  those  in  other  chronic 
inflammations  affecting  mucous  surfaces,  namely,  thickening  and 
more  or  less  infiltration  of  the  mucous  membrane,  increased  pro- 
liferation and  exfoliation  of  the  epithelial  cells,  and  increased 
functional  activity  of  the  muciparous  follicles. 

In  the  adult  chronic  laryngitis  is  common  as  one  of  the  lesions 
of  the  syphilitic  or  tubercular  disease.  In  the  child  this  disease  is 
more  rare,  but  it  sometimes  occurs  in  connection  with  pulmonar}^ 
or  bronchial  tubercles.  Such  patients  are  emaciated,  and  have  the 
ordinary  symptoms  of  tuberculosis.  Chronic  laryngitis  also  occurs 
in  young  children,  usually  infants,  as  one  of  the  manifestations  of 
the  strumous  diathesis.  I  have  records  of  about  twelve  such  cases, 
mostly  nursing  infants.  Some  of  these  patients  had  mild  bronchitis, 
but  it  was  obviously  subordinate  to  the  laryngitis.  Their  respira- 
tion was  noisy  and  harsh,  continuing  of  this  character  for  several 
weeks  and  even  months.  The  cough  was  also  harsh  and  loud, 
conveying  the  idea  of  thickening  and  relaxation  of  the  mucous 
membrane  covering  the  vocal  cords.  Their  respiration  was  not 
notably  accelerated,  and  the  blood  was  apparently  fully  oxygenated, 
though  the  friends  were  often  alarmed  by  the  noisy  breathing  and 
cough. 

In  this  form  of  chronic  laryngitis  there  is  little  expectoration, 
the  fever  is  slight  or  absent,  the  appetite  remains  unimpaired,  and 
the  general  condition  of  the  child  is  good.  There  are  from  time 
to  time  exacerbations,  and  occasionally  improvement  is  such  as  to 
encourage  the  hope  of  speedy  cure,  but  in  the  cases  which  I  have 
seen  there  has  not  been  complete  intermission  in  the  disease  till 
the  final  recovery.  Those  patients  whom  I  have  been  able  to 
follow  through  the  disease  have  recovered  in  from  three  or  four 
months  to  one  year. 

This  chronic  laryngitis  is  to  be  distinguished  from  frequent 
attacks  of  acute  laryngitis,  which  are  due  to  fresh  exposures,  and 
are  accompanied  by  the  ordinary  symptoms  of  the  acute  disease. 
It  is  to  be  distinguished  from  protracted  acute  laryngitis,  which 
sometimes  does  not  entirely  subside  in  less  than  a  month  or  six 


,  TREATMENT.  451 

weeks,  by  its  lono'cr  duration,  the  greater  tliickening  of  the  iii- 
tiamed  lucnibrane,  and  more  noisy  respiration.  (Certain  cases  of 
chronic  hiryngitis  result  from  tlie  acute  disease,  the  inflammation 
lieing  perpetuated  by  the  struma  or  dyscrasia  of  the  patients. 

Anatomical  Ciiaragters. — In  simple  acute  laryngitis  the  mucous 
membrane  of  the  larynx  presents  the  usual  appearance  of  mucous 
surfaces  when  inflamed,  namely,  redness  and  thickening.  It  is  also 
somewhat  softened.  Ulcerations  rarely,  perhaps  never,  occur  in 
primary  acute  laryngitis.  When  present  in  chronic  laryngitis,  the 
ulcers  are  small  and  situated  upon  or  near  the  vocal  cords.  Tu- 
bercular and  syphilitic  ulcers  of  the  larynx  are  much  more  rare  in 
children  than  adults.  The  inflammation  in  simple  acute  laryngitis 
usually  extends  over  the  whole  surface  of  the  larynx,  and  also  to 
the  upper  part  of  the  trachea.  It  may  be  pretty  uniform,  or  more 
intense  in  one  place  than  another,  and,  like  other  mucous  inflam- 
mations, it  is  accompanied  by  more  or  less  rapid  proliferation  and 
exfoliation  of  epithelial  cells.  In  most  cases  of  simple  laryngitis, 
whether  acute  or  chronic,  the  inflammation  extends  to  the  pharynx, 
producing  redness  and  thickening,  though  generally  moderate,  of 
the  mucous  membrane  which  covers  it.  Examination  of  the  fauces 
therefore  aids  in  diagnosis. 

In  the  adult  cedema  glottidis  occasionally  results  from  laryn- 
gitis. In  the  child  there  is  little  danger  that  this  will  occur,  in 
consequence  of  the  anatomical  character  of  the  larynx.  In  early  life 
there  is  but  little  submucous  connective  tissue  in  the  larynx,  and 
therefore  less  submucous  infiltration  or  eftusion  during  the  inflam- 
mation. The  structural  changes  occurring  in  simple  laryngitis  of 
infancy  and  childhood  relate  almost  exclusively  to  the  mucous, 
membrane. 

Treatment. — Simple  primary  and  uncomplicated  laryngitis  re- 
(piires  little  treatment.  Most  cases  would  do  well  by  the  employ- 
ment of  suitable  hygienic  measures,  without  medicines.  Benefi.t 
is,  however,  derived  from  the  use  of  demulcent  drinks  and  an 
occasional  laxative.  A  mixture  of  paregoric  and  syrup  of  ipecacu- 
anha, or  a  small  Dover's  powder,  will  relieve  the  cough  if  it  is 
troublesome.  If  there  is  restlessness,  a  warm  mustard  foot-bath  is 
useful.  An  important  part  of  the  treatment  is  the  application  of 
some  mild  counter-irritant  over  the  larynx.  In  most  instances 
camphorated  oil,  preceded  perhaps  by  mustard,  produces  sufiicient 
irritation.  It  should  be  rubbed  several  times  daily  over  the  throat, 
or  a  strip  of  flannel  soaked  with  it  may  be  applied  around  the^ 
neck.     Chronic  laryngitis  dependent  on  syphilis  or  tuberculosis. 


•i52  SPASMODIC    LARYNGITIS. 

requires  the  constitutional  treatment  which  is  approi:^nate  for  that 
disease.  Local  measures  have  hut  little  effect  upon  this  form  of 
inflammation.  The  chronic  laryngitis  which  I  have  described  as 
occurring  chiefly  in  infancy,  and  which  appears  to  be  of  a  strumous 
character,  is  apt  to  be  obstinate.  The  patient  should  be  warmly 
clothed,  and  constant  care  should  be  taken  that  there  be  no 
exposure  which  would  endanger  taking  cold,  as  this  would  inevi- 
tably produce  an  exacerbation  of  the  disease,  and  counteract  all 
that  had  been  gained  by  remedial  measures.  This  form  of  chronic 
laryngitis  is  most  satisfactorily  treated  b}'  the  application  of 
tincture  of  iodine  upon  the  neck,  directly  over  the  larynx,  and  the 
internal  use  of  cod-liver  oil  and  the  syrup  of  the  iodide  of  iron. 
Little  benefit  results  in  this  form  of  laryngitis  from  the  usual  ex- 
pectorant remedies,  as  squills  or  senega. 

Spasmodic  Laryngitis. 

This  is  a  common  disease.  It  is  also  called  false  croup,  in  con- 
tradistinction to  true  or  pseudo-membranous  croup,  and,  by  some 
of  the  continental  writers,  stridulous  angina  or  stridulous  larjai- 
gitis.  It  should  not  be  confounded  with  spasm  of  the  glottis, 
which  is  a  form  of  internal  convulsions,  and  is  not  inflammatory. 
It  occurs  ordinarily  between  the  ages  of  two  and  five  years.  It  is 
commonly  a  sporadic  affection,  but  Eilliet  and  Barthez  state  that 
"it  is  incontestable  that  it  may  prevail  epidemical!}'."  They 
express  this  opinion,  not  from  their  own  observations,  but  chiefly 
from  those  of  Jurine,  made  in  the  commencement  of  the  present 
centurv. 

Causes.  —  Children  in  some  families  are  more  liable  to  false 
croup  than  in  others,  so  that  an  hereditary  tendency  to  it  must  be 
admitted.  The  exciting  cause  in  most  cases  is  exposure  to  cold. 
False  croup  is  not  uncommon  in  the  commencement  of  measles. 
iSTarrowness  of  the  rima  glottidis,  and  an  excitable  state  of  the 
nervous  system,  both  of  which  are  common  in  early  childhood, 
are  predisposing  causes. 

Symptoms. — Spasmodic  laryngitis  is  ordinarily  preceded  for  a 
day  or  two  by  a  slight  cough  and  fever,  by  symptoms  of  mild 
coryza  or  catarrh,  such  as  all  children  are  liable  to  on  taking  cold. 
In  exceptional  cases  these  sjmiptoms  are  absent,  and  the  disease 
begins  abruptly.  Singularly,  it  commences  nearly  always  at 
night,  after  the  first  sleep,  between  ten  and  twelve  o'clock.  The 
sleep  is  usually  quiet  and  natural,  but  the  child  awakens  with  a 


SYMPTOMS,  453 

loud,  barking  cough.  There  is  great  dyspnoia,  and  the  rcsj/iration 
is  harsh  or  wliistling,  on  account  of  the  narrowing  of  tlie  cliink  of 
the  glottis  from  the  swelling  and  tension  of  the  vocal  cords.  The 
face  is  flushed  and  indicative  of  suffering.  The  child  cries,  moves 
from  one  position  to  another,  wishes  to  be  held  or  carried,  seeking 
in  vain  for  relief.  The  skin  is  hot,  pulse  accelerated,  the  voice 
hoarse  or  even  whispering.  After  a  variable  period,  usually  from 
half  an  hour  to  two  or  three — not  more  than  half  an  hour  with 
proper  treatment — these  symptoms  abate.  The  patient  is  then 
somewhat  exhausted,  and  falls  asleep.  The  face  is  less  flushed 
or  even  pallid,  the  heat  abates,  and  the  pulse  is  less  accelerated. 
The  cough,  though  less  frequent,  remains  for  a  time  barking  or 
sonorous,  and  the  respiration,  though  greatly  relieved,  is  not  at 
once  entirely  natural,  but  it  gradually  becomes  so.  Often  there  is 
no  return  of  the  spasmodic  respiration  and  cough,  but  sometimes 
the  attack  is  repeated  once  or  more,  especially  during  the  subse- 
quent nights.  The  symptoms  vary  greatly  in  intensity  in  different 
patients. 

As  the  attack  declines,  the  disease,  losing  its  spasmodic  character, 
becomes  a  simple  inflammation.  In  some  there  is  immediate  return 
to  perfect  health,  but  oftener  the  inflammation  extends  not  only 
into  the  trachea,  but  also  into  the  larger  bronchial  tubes,  and  the 
disease  is  then  a  laryngo-bronchitis,  which  gradually  subsides. 

The  termination  is  not  always  so  favorable.  Spasmodic  laryn- 
gitis is,  in  exceptional  instances,  the  precursor  of  other  serious 
aftections,  which  may  prove  fatal.  It  has  been  stated  that  measles 
often  begins  with  spasmodic  laryngitis.  Bronchitis  becoming 
capillary,  may  occur  in  connection  with  it,  as  may  also  pneumonia, 
and  by  either  of  these  severe  inflammations  the  prognosis  may  be 
rendered  doubtful.  There  are  a  few  cases  on  record  in  which  it 
is  believed  that  spasmodic  laryngitis  was  of  itself  fatal.  In  some 
of  these  cases  the  dyspnoea  was  extreme  and  persistent,  and  was 
the  cause  of  death.  In  a  case  reported  by  Rogery,  on  the  other 
hand,  the  respiration  became  easy  before  death,  and  the  pulse  more 
and  more  frequent  and  feeble.  Death  apparently  occurred  from 
exhaustion.  It  is  not  improbable  that,  had  careful  post-mortem 
examinations  been  made,  in  those  cases  of  spasmodic  laryngitis 
which  have  ended  fatally,  other  lesions  would  have  been  discovered 
besides  those  located  in  the  larynx,  perhaps  tracheo-bronchitis, 
with  an  accumulation  of  mucus  in  the  larynx,  producing  suffoca- 
tion, or  perhaps  sometimes  congestion  of  the  brain  or  lungs  and 
serous  eftusion. 


454  SPASMODIC    LARYNGITIS. 

AxATOMiCAL  Character;  Pathology. — The  opportunity  does  not 
often  occur  of  determining  the  anatomical  characters  of  spasmodic 
larvno:itis.  I  have  witnessed  but  one  post-mortem  examination. 
A  little  girl,  nine  years  old,  was  taken  on  Friday  night  with  cough 
and  dyspnoea,  indicating  a  pretty  severe  attack.  The  mother, 
actino-  throu<2;h  the  advice  of  a  friend,  gave  kerosene  oil  to  her  in 
considerable  quantity.  This  was  succeeded  by  obstinate  vomiting 
and  purging,  which  continued  during  Saturday  and  Sunday. 
Death  occurred  on  Monday.  At  the  autopsy  we  found  uniform 
and  intense  injection  throughout  the  whole  extent  of  the  larynx 
and  trachea,  and  extending  into  the  bronchial  tubes.  There  was 
no  pseudo-membrane  on  the  inflamed  surface,  and  but  little  mucus 
and  pus.  The  solitary  follicles  of  the  intestines  and  Peyer's 
patches  were  tumefied.  There  was  injection,  in  places,  of  the 
gastro-intestinal  mucous  membrane.  The  cause  of  death  was 
obviously  the  diarrhoea,  apparently  of  an  inflammatory  character, 
and  probably  produced  by  the  kerosene  oil.  The  condition  of  the 
mucous  membrane  of  the  larynx  w^as  that  which  is  ordinarily 
present  in  spasmodic  laryngitis,  though  in  some  cases  in  which 
post-mortem  examinations  have  been  made  the  evidences  of  laryn- 
ofcal  inflammation  were  slig-ht.  Guersant  relates  a  case  in  which 
the  surface  of  the  larynx  seemed  to  be  nearly  in  its  normal  state. 
Death  in  cases  of  slio'ht  laryngitis  is  due  to  causes  which  are 
independent  of  the  larynx.  In  Guersant's  case  there  was  tuber- 
culosis. 

There  is,  as  has  already  been  intimated,  another  and  an  impor- 
tant element  besides  the  inflammation,  in  the  pathology  of  spas- 
modic laryngitis — an  element  producing  those  phenomena  which 
render  it  a  disease  distinct  from  simple  laryngitis.  I  refer  to  spasm 
of  the  laryngeal  muscles.  This  element  pertains  to  the  nervous 
system,  so  that  spasmodic  laryngitis  is  allied  both  to  the  neuroses 
and  to  the  inflammations.  ^ 

Diagnosis. — The  disease  for  which  sj)asmodic  laryngitis  is  most 
frequently  mistaken  is  pseudo-membranous  croup.  The  friends, 
indeed,  usually  make  this  mistake  in  forming  their  opinion  of  the 
case  before  the  physician  arrives  ;  and  there  can  be  no  doubt  that 
many  of  the  cases  which  physicians  have  pvdjlished  in  medical 
journals  as  true  croup  were  examples  of  this  aftcction.  The  points 
of  difl'erential  diagnosis  are  the  following :  True  croup  begins 
with  symptoms  which  at  first  are  slight,  so  as  scarcely  to  arrest 
attention,  but  which  gradually  increase  in  intensity.  The  cough 
becomes  more  harsh,  and  the  respiration  more  diflicult,  by  degrees. 


PROGNOSIS  —  TJIEATMENT.  455 

This  increase  in  the  gravity  of  the  symptoms  occurs  by  day  as 
well  us  by  night.  On  the  other  hand,  false  croup,  though  preceded 
by  symi)toms  of  coryza,  or  catarrh,  begins  al)ru})tly.  The  symp- 
toms have  from  the  first  their  maximum  intensity,  and  the  time 
at  which  it  commences  is  the  night.  Again,  the  cough  in  spas- 
modic laryngitis  possesses  a  loud,  sonorous  character;  while  in  true 
croup  it  is  harsh  or  rough,  from  the  presence  of  the  membrane, 
and  having,  therefore,  less  fulness.  The  voice  in  spasmodic  laryn- 
gitis may  be  hoarse,  but  it  is  not  lost,  or  is  lost  only  for  a  short 
time.  It  afterwards  becomes  natural,  or  is  slightly  hoarse.  On 
the  other  hand,  in  true  croup,  the  voice,  from  being  natural  at 
first,  is  gradually  extinguished.  In  fatal  cases  it  soon  becomes 
whispering,  and  continues  such  till  the  close  of  life ;  in  those  that 
recover,  the  voice  remains  hoarse  for  several  days.  These  differ- 
ences are  important,  and,  if  fully  appreciated,  are  in  most  instances 
sufficient  to  establish  the  diagnosis.  Besides,  in  a  large  proportion 
of  cases  of  true  croup,  portions  of  the  pseudo-membrane  may  be 
discovered  on  inspecting  the  fauces,  and  the  faucial  surface  is 
deeply  injected,  while  in  spasmodic  laryngitis  there  is,  with  rare 
exceptions,  no  false  membrane  upon  the  surface  of  the  fauces,  and 
but  a  moderate  amount  of  congestion. 

Laryngismus  stridulus,  or  internal  convulsions,  must  not  be 
confounded  with  this  disease.  It  is  not  inflammatory,  but  purely 
spasmodic,  suddenly  commencing  and  abating — identical,  it  is 
believed,  in  character,  with  tonic  convulsions  of  the  external  mus- 
cles, but  affecting  the  internal  muscles  of  respiration.  This  disease 
has  already  been  fully  described. 

Prognosis. — Little  need  be  added,  as  regards  the  prognosis,  to 
what  has  alreadj^  been  stated.  While  a  favorable  opinion  in 
reference  to  the  result  may  ordinarily  be  expressed,  the  physician 
should  not  forget  the  fact  that  death  may  occur.  Symptoms  indi- 
cating an  unfavorable  termination  are :  great  and  continued  dysp- 
noea, not  diminished  by  the  proper  remedial  measures ;  stridulous 
expiration  as  well  as  inspiration ;  lividity  of  the  prolabia  and  fin- 
gers ;  pallor  and  coldness  of  surface ;  pulse  progressivel}^  more 
frequent  and  feeble.  Convulsions  and  coma  may  also  occur  near 
the  close  of  life. 

Treatment. — The  indications  of  treatment  are  twofold :  first,  to 
relieve  the  spasmodic  action  of  the  laryngeal  muscles ;  secondly,  to 
cure  the  laryngitis.  To  meet  the  first  indication,  a  warm  bath  of 
the  temperature  of  about  100°  should  be  employed  as  soon  as  possi- 
ble after  the  commencement  of  the  attack.     The  patient  should  be 


456  SPASMODIC    LARYNGITIS. 

kept  ill  it  ten  or  fifteen  minutes,  in  order  to  obtain  its  full  relaxing 
eftect.  In  mild  cases  a  warm  foot-batli  may  be  sufficient.  A 
second  means  is  the  use  of  an  emetic,  which  should  be  simultaneous 
with  the  bath.  To  children  under  the  age  of  three  years,  syrui3  of 
ipecacuanha  should  be  given,  in  doses  of  one  teaspoonful,  repeated 
in  twentj'' minutes,  till  vomiting  occurs;  or  alum  and  syrup  of 
ipecacuanha,  two  drachms  of  the  former  to  one  ounce  of  the  latter, 
may  be  given  in  the  same  dose.  The  alum  and  the  syrup  produce 
more  prompt  emesis  than  the  syrup  alone.  Children  over  the  age 
of  three  years,  unless  of  feeble  constitutions,  are  best  treated  by 
the  compound  syrup  of  squills  in  teaspoonful  doses,  or  a  mixture  of 
this  with  sj'rup  of  ipecacuanha.  It  is  not  often  necessary  to  give 
more  than  three  or  four  doses,  and  sometimes  one  or  two  are  suffi- 
cient to  produce  vomiting. 

In  most  cases,  by  the  use  of  the  warm  bath  and  the  emetic,  the 
symptoms  are  rendered  milder,  and  convalescence  soon  commences. 

In  the  American  Journal  of  the  3Iedical  Sciences^  April,  1867,  Dr. 
R.  R.  Livingston  reports  a  case  of  laryngitis  treated  by  Squibb's 
ether.  It  is  stated  that  portions  of  pseudo-membrane,  from  one- 
eighth  to  three-fourths  of  an  inch  in  length,  were  expectorated; 
but  the  symptoms  certainly  indicated  a  spasmodic  element  as 
decided  as  in  spasmodic  croup,  and  the  benefit  from  the  ether  was 
apparently  due  to  the  relaxation  of  tlie  laryngeal  muscles  which 
it  produced.  The  treatment  of  the  patient,  who  Avas  two  years 
old,  was  commenced  by  the  administration  by  the  mouth  of  half 
a  teaspoonful  of  the  ether,  and  followed  by  its  inhalation.  "In 
precisely  eight  minutes  from  the  time  the  patient  commenced  the 
inhalation,  the  abnormal  muscular  exertion  ceased ;  a  general 
relaxation  took  place;  the  pulse  (which  had  numbered  150)  fell 
to  100."  Ether,  judiciously  employed,  will  probably  prove  to  be 
a  useful  remedial  agent  in  spasmodic  forms  of  laryngitis,  wliether 
or  not  it  has  any  effect  on  pseudo-membranous  formations.  The 
same  may  be  said  of  chloroform.  A  large  majority  of  cases, 
however,  recover  speedily  without  its  employment,  by  the  other 
measures  recommended. 

To  fulfil  the  second  indication,  namely,  the  cure  of  the  inflam- 
mation, as  well  as  to  control  the  spasm  of  the  laryngeal  muscles, 
bloodletting  has  sometimes  been  resorted  to.  It  is,  however,  so 
seldom  required,  that  it  may  be  almost  discarded  as  a  part  of  the 
treatment.  In  those  of  full  habit,  with  strong  pulse,  if  the  mea- 
sures already  recommended  should  not  give  relief,  one  or  two 
leeches  might  be  advantageously  applied  to  the  top  of  the  stcr- 


TREATMENT.  ioi 

niim ;  but,  except  in  such  cases,  local  bloodletting,  and  much  less 
general,  should  not  be  resorted  to. 

Attention  should  always  be  given  to  the  state  of  the  bowels  in 
spasmodic  laryngitis.  If  they  are  not  well  open,  a  purgative 
should  be  administered.  For  those  that  are  robust,  and  with 
considerable  febrile  movement,  the  saline  cathartics  are  ordinarily 
preferable,  as  Rochelle  salts,  or  a  purgative  dose  of  calomel  may 
be  administered.  The  cathartic  should  not  be  prescribed  till  the 
nausea  from  the  emetic  has  subsided.  By  its  derivative  eifect,  it 
tends  to  diminish  the  laryngitis,  and,  in  severe  cases,  it  may  ob- 
viate the  need  of  depletion  by  leeches. 

Inhalation  of  the  vapor  of  hot  water,  and  the  application  of  a 
sinapism  over  the  neck  and  upper  part  of  the  sternum,  followed  by 
an  emollient  poultice,  are  useful  adj  u vants  to  the  treatment. 

"When  the  spasmodic  element  in  the  disease  is  relieved,  the  case 
becomes  one  of  simple  laryngitis,  and  the  general  plan  of  treat- 
ment recommended  for  that  disease  is  proper  for  this.  Small 
doses  of  ipecacuanha,  or  of  one  of  the  antimonial  preparations,  as 
the  compound  syrup  of  squills,  not  sufficient  to  cause  nausea, 
should  now  be  given  at  regular  intervals.  I  have  sometimes 
added  to  the  expectorant  one  drop  of  tincture  of  veratrum  viride, 
for  robust  children  over  the  age  of  three  or  four  years,  having  a 
full  and  rapid  pulse,  flushed  face,  and  other  evidences  of  active 
febrile  movement.  Its  eft'ect  should  be  watched,  and  it  should  be 
discontinued  when  its  sedative  influence  on  the  circulation  begins 
to  be  apparent.  It  should  not  be  given  in  the  spasmodic  laryngitis 
which  occurs  in  the  commencement  of  measles. 

If,  however,  there  is  not  a  speedy  termination  of  the  disease  by 
recover}^,  or,  more  rarely,  by  death,  there  is  nearly  always  tracheo- 
bronchitis, or  a  more  serious  affection,  coexisting  with  the  laryn- 
gitis, or  following  it;  therefore,  depressing  measures  should  not 
be  long  continued.  Expectorants  of  a  stimulating  character,  as 
carbonate  of  ammonia,  or  syrup  of  senega,  are  required  in  the 
course  of  a  few  days,  and  in  young  and  feeble  children  they  should 
be  given  at  an  early  period. 

The  mode  of  treatment  recommended  above  is  appropriate  for 
that  large  class  in  whom  the  inflammatory  element  predominates. 
In  a  smaller  number  of  cases  the  nervous  element  predominates 
over  the  inflammatory,  and  the  treatment  should  be  in  some  re- 
spects different.  Such  children  are  usually  pallid  and  of  spare 
habit,  having,  indeed,  the  nervous  temperament.  They  are  liable 
to  attacks  of  this  disease,  though  generally  of  a  mild  form,  on 


458  PSEUDO-MEMBRANOUS    LARYNGITIS. 

slight  exposure  to  cold,  and  with  a  very  moderate  amount  of  in- 
Hammatioii.  The  treatment  in  these  cases  should  be  directed  more 
to  the  nervous  system.  My  plan  has  been,  in  the  treatment  of  such 
cases,  after  perhaps  the  use  of  a  mild  emetic,  to  give  quinine,  one 
strain  three  or  four  times  daily,  to  a  child  from  three  to  five  years 
old,  prescribing  at  the  same  time  a  simple  expectorant,  as  syrup  of 
squills,  and  a  mildly  irritating  application  to  the  throat.  The 
symptoms  in  these  cases  are  not  severe,  and  active  measures  are 
not  required,  though  the  peculiar  cough  continues  longer  than  in 
the  more  inflammatory  forms  of  the  disease. 

The  patient  with  spasmodic  laryngitis  should  be  kept  in  a  warm 
room  during  tlie  paroxysms,  and  should  inhale  an  atmosphere 
loaded  with  moisture. 

Trousseau  recommends  a  mode  of  treatment  of  spasmodic  laryn- 
critis  which  was  first  suggested  by  Graves,  of  Dublin.  It  consists 
in  the  application  underneath  the  chin,  so  as  to  cover  the  larynx, 
of  a  sponge  soaked  in  water  as  hot  as  can  be  borne ;  in  ten  or 
fifteen  minutes  it  is  repeated.  This  reddens  the  skin,  producing 
revulsion  from  the  larynx.  The  hoarseness,  dyspnoea,  and  cough 
diminish  with  this  treatment,  and  some  recover  without  other 
measures. 

Guersant  and  others  speak  of  the  importance  of  prophylactic 
manao-ement  of  children  who  are  liable  to  this  disease.  Attention 
should  be  given  to  the  dress,  so  that  there  may  be  sufficient 
protection  from  changes  of  temperature,  and  there  should  be  an 
equable  temperature  of  the  apartments  in  which  the}^  reside. 
Children  of  a  decidedly  nervous  temperament,  in  whom  the 
slightest  laryngitis  is  ajtt  to  be  spasmodic,  require  additional 
jtrophylactic  measures.  They  are  pallid,  and  in  a  more  or  less 
cachectic  state.  Such  children  are  benefited  by  chalybeate  and 
vegetable  tonics,  and  by  exercise  in  suitable  weather  in  the  open 
air. 


CHAPTER   III. 
PSEUDO-MEMBEANOUS  LARYNGITIS. 

The  term  pseudo-membranous  laryngitis,  or  true  croup,  is  applied 
to  a  common  and  fatal  disease,  the  essential  anatomical  character 
of  which  is  inflammation  of  the  mucous  membrane  of  the  larynx, 
with  the  formation  upon  its  surface  of  a  pseudo-membrane.     It 


ANATOMICAL    CnARACTERS.  459 

occurs  most  frequently  between  the  ages  of  two  and  seven  years. 
It  is  rare  in  adult  life,  and  also  under  the  age  of  six  months. 

Causes. — There  is  greater  liability  to  this  disease  in  some  chil- 
dren than  in  others,  and  occasionally  the  predisposition  to  it 
appears  to  be  inherited.  The  common  exciting  cause  is  exposure 
to  cold.  Those  children,  especially,  are  liable  to  croup,  who  live  in 
heated  apartments,  and  are  taken  into  the  open  air  without  proper 
covering,  and  those  who  a  part  of  the  time  are  warmly  and  a  part 
of  the  time  thinly  clothed,  especially  as  regards  the  covering  of 
the  neck.  This  disease  is  common  among  the  poor  of  New  York, 
who  live  in  close  rooms,  overheated  through  the  day  and  cool  at 
night.  Another  less  common  cause  is  the  inhalation  of  irritating 
vapors,  or  swallowing  irritating  or  corrosive  liquids.  I  have 
known  a  child  to  die  from  swallowing  acetic  acid,  and  another 
from  scalding  water,  both  having  the  dyspnoea  and  cough  of  true 
croup. 

This  disease  is  ordinarily  primary,  but  occasionally  it  is  second- 
ary. The  secondary  form  is  not  unusual  in  the  declining  period  of 
measles,  and  it  is  an  occasional  complication  of  scarlet  fever.  Croup 
is  most  common  in  the  winter  months,  and  in  times  of  changeable 
weather.  It  is  said,  also,  that  it  sometimes  occurs  as  an  epidemic, 
but  it  is  a  question  whether  the  supposed  epidemics  may  not  have 
been  diphtheritic. 

Anatomical  Characters. — The  inflammatory  action  in  this  dis- 
ease affects  not  only  the  mucous  membrane,  but,  in  a  certain  pro- 
portion of  cases,  extends  to  the  submucous  connective  tissue,  caus- 
ing infiltration  or  cedema.  The  mucous  membrane  itself  undergoes 
similar  alteration  to  that  in  simple  or  spasmodic  laryngitis,  con- 
sisting of  hypersemia  and  thickening,  proliferation,  and  rapid 
desquamation  of  its  epithelial  cells,  and  an  abundant  production  of 
muco-pus.  Sometimes  the  redness  is  found  only  in  patches  at  the 
autopsy ;  in  other  cases  it  extends  over  the  Avhole  surface  of  the 
larynx,  while  occasionally  it  has  disappeared  so  that  the  laryngeal 
mucous  membrane,  though  thickened  and  softened,  presents  nearly 
its  normal  color.  In  all  except  the  mildest  cases  the  inflammation 
extends  further  than  the  larynx,  involving  not  only  the  surface  of 
the  pharynx,  but  also  in  greater  or  less  degree  that  of  the  trachea 
and  bronchial  tubes. 

The  distinguishino;  feature  as  re2:ards  the  anatomical  character 
of  this  disease  remains  to  be  noticed,  namely,  the  false  membrane 
which  covers  the  laryngeal  and  often  contiguous  surfaces.  This 
has  long  been  considered  as  consisting  of  fibrin,  which,  exuding 


460  PSEUDO-MEMBRANOUS    LARYNGITIS. 

in  its  liquid  state  from  the  submucous  vessels,  became  fibrillatecl 
when  exposed  to  the  air,  its  interstices  being  filled  with  a  greater 
or  less  amount  of  pus,  epithelial  cells,  and  amorphous  matter.  At 
a  recent  date  Wagner  has  surprised  pathologists  by  the  statement 
that  these  pseudo-membranes  contain  no  fibrin,  but  that  they 
consist  of  epithelial  cells,  which,  undergoing  some  form  of  degenera- 
tion as  they  are  pushed  forward  from  the  mucous  surface,  enlarge, 
and  appear  under  the  microscope  as  irregular  blocks  interlacing 
with  each  other.  By  employing  the  picro-carminate  of  ammonia, 
or  a  weak  ammoniacal  solution  of  carmine,  "Weber  and  other  micro 
scopists  have  been  able  to  trace  the  boundaries  of  these  irregular 
and  interlacing  blocks,  which  have  prolongations  like  the  shape  of 
a  stag's  horns,  and  they  have  observed  the  intermediate  forms  of 
transition  between  these  and  the  normal  epithelial  cells. 

The  views  of  Wagner  are  now  generally  admitted  to  be  in  the 
main  connect  as  regards  the  pseudo-membrane  of  croup,  but  some 
of  the  highest  autliorities  in  pathological  histology,  as  Rindfieisch, 
state  that  they  find  fibrin  in  the  pseudo-membrane,  in  addition  to 
the  enlarged  and  degenerated  epithelial  cells  of  which  it  is  chiefly 
composed.  Rindfleisch  says:  "The  pseudo-membrane  is  of  a  pecu- 
liarly stratified  structure,  since  upon  a  layer  of  cells  at  tolerably 
equal  distances  there  always  follows  a  layer  of  fibrin,  and  this 
sequence  is  repeated  from  one  to  ten  times,  according  to  the  thick- 
ness of  the  membrane."  {Patholog.  UistoL,  translated,  page  351.) 
As  lending  support  to  the  views  that  the  pseudo-membrane  does 
contain  fibrin,  the  fact  may  be  stated,  that  while  in  the  ordinary 
pneumonia  of  young  children  there  is  no  fibrinous  exudation 
in  the  air-cells,  this  exudation  does  occur,  at  least  in  a  certain 
proportion  of  cases,  in  pneumonia  occurring  as  a  complication 
of  croup.  Thus,  recently  in  this  city,  in  a  pneumonic  lung  from  a 
case  of  fatal  croup,  occurring  at  the  age  of  about  two  years.  Dr. 
Francis  Delafield  found  fibrin  in  the  exudat  of  the  air-cells.  The 
exact  nature  of  the  degeneration  which  the  epithelial  cells  undergo 
is  unknown.  It  is  generally  believed  that  they  are  infiltrated  by 
an  albuminate,  but  AVeber  holds  the  opinion  that  the  substance  is 
fibrin.  MAI.  Cornil  and  Ranvier,  on  the  other  hand,  state:  "AVe 
have  verified  the  correctness  of  the  description  given  by  AVagner ; 
we  have  separated  and  colored  the  cells  by  means  of  the  picro- 
carminate  of  ammonia,  and,  in  consequence  of  the  facility  which 
they  present  of  fixing  the  carmine,  we  conclude  that  they  are  not 
filled  with  fibrin,  Init  rather  by  a  matter  resembling  mucine. 
These  exudats  of  true  croup  are  pressed  forward  and  detached  in 


ANATOMICAL    CHARACTERS.  461 

proportion  as  the  globules  of  pns  or  new  epithelial  cells  are  pro- 
duced underneath  them,"  The  pseudo-membrane  varies  greatly 
in  amount  in  difierent  cases.  It  may  occur  only  in  points  or  small 
patches,  which  are  generally  found  in  the  vicinity  of  the  vocal 
cords,  while  in  other  cases  it  extends  an  almost  continuous  mem- 
brane from  the  epiglottis  into  the  bronchial  tubes,  and  there  is  every 
gradation  between  these  two  extremes.  It  fills  the  orifices  of  the 
muciparous  follicles,  and  the  minute  depressions  upon  the  mucous 
surface,  being  closely  adherent,  so  as  not  to  be  detached  by  eltbrts 
of  coughing  or  vomiting,  except  in  small  portions. 

As  the  inflammation  commonly  extends  beyond  the  larynx,  so 
the  pseudo-membrane,  in  a  large  proportion  of  cases,  is  formed  not 
only  upon  the  laryngeal,  but  also  upon  contiguous  surfaces.  In 
thirty-three  cases  of  true  croup,  comprised  in  the  statistics  of  Dr. 
Ware,  of  Boston,  pseudo-membranous  pharyngitis  was  also  present 
in  all  but  one ;  and  in  nineteen  cases  observed  by  Dr.  Meigs,  of 
Philadelphia,  in  all  but  three.  The  formation  of  a  pseudo-mem- 
brane in  the  trachea  in  connection  with  that  in  the  larynx  is  also 
common,  and  it  is  not  infrequent  in  the  bronchial  tubes.  M.  Guer- 
sant  has,  so  far  as  I  am  aware,  collected  the  largest  number  of  records 
relating  to  the  extent  of  the  pseudo-membrane  in  true  croup.  In 
an  aggregate  of  120  cases  it  was  confined  to  the  larynx  and  trachea 
in  78,  or  about  two-thirds,  while  in  the  remainder,  namely,  42,  it 
extended  into  the  bronchial  tubes. 

In  those  whose  systems  are  robust,  the  false  membrane  is  usually 
firmer  than  in  those  whose  systems  are  reduced.  In  a  state  of 
decided  cachexia  it  is  sometimes  friable  and  easily  detached.  If 
the  case  continues  from  four  to  six  days,  it  begins  to  soften  from 
commencing  decomposition,  the  minute  fibres  which  attach  it  to 
the  mucous  membrane  give  way,  and,  in  favorable  cases,  by  the 
effort  of  coughing  or  vomiting  it  is  thrown  off".  Separation  is 
aided  by  muco-pus,  which  collects  underneath.  In  fatal  cases  the 
false  membrane,  if  detached  by  the  efforts  of  the  child,  is  rapidly 
reproduced,  so  that  in  twelve  to  eighteen  hours  the  dyspnoea  re- 
turns. Pneumonia  not  infrequently  complicates  croup.  In  extrejne 
cases,  in  which  inspiration  is  difficult  in  consequence  of  the  obstruc- 
tion, the  lungs  are  only  partially  inflated,  and  imperfect  decarboni- 
zation  of  the  blood  and  sometimes  collapse  of  certain  pulmonary 
lobules  are  the  result.  Occasionally  there  is  that  degree  of  thick- 
ening of  the  mucous  membrane,  and  submucous  infiltration,  that 
the  dyspnoea  and  danger  occur  more  from  these  than  from  the 
presence  of  the  pseudo-membrane. 


462  PSEUDO-MEMBRANOUS    LARYNGITIS. 

Symptoms. — In  some  cases,  pseudo-membranous,  like  simple  laryn- 
gitis, is  preceded  by  coryza  and  pharyngitis,  while  in  others  laryn- 
gitis is  present  from  the  first.  The  commencement  of  croup  is 
indicated  not  only  by  fever,  diminished  appetite,  thirst,  and  such 
symptoms  as  accompany  all  acute  inflammations,  but  by  certain 
other  symptoms  which  serve  to  distinguish  this  from  all  other 
diseases. 

The  cough  is  one  of  the  earliest  symptoms  which  distinguish 
true  croup  from  other  laryngeal  inflammations.  It  is  hoarse  or 
harsh ;  its  character  may  be  expressed  by  the  term  dry  or  suppressed. 
It  difters  from  the  cough  of  spasmodic  laryngitis,  which  is  less 
hoarse  and  more  sonorous.  It  is  much  more  frequent  in  some  cases 
than  in  others ;  in  many  patients,  towards  the  close  of  life,  it  nearly 
or  quite  ceases.  Hoarseness  of  the  voice  is  also  one  of  the  first  and 
most  constant  symptoms,  and  it  continues  throughout.  Towards 
the  close  of  life  the  voice  is  usually  lost,  and  the  child  expresses 
its  thoughts  in  an  indistinct  whisper. 

The  amount  of  expectoration  varies  considerably  in  difterent 
patients,  according  to  the  presence  or  absence  of  bronchial  inflam- 
mation. If  the  inflammation  extends  no  lower  than  the  upper  part 
of  the  trachea,  the  sputum  is  scanty  during  the  whole  course  of 
the  disease.  In  ordinary  cases  it  is  scanty  at  first,  then  more 
abundant,  and  again  more  scanty  if  the  case  is  fatal.  The  scanti- 
ness of  the  sputum  towards  the  close  of  life  is  due  not  entirely  to 
exhaustion  of  the  patient,  but  in  part  to  obstruction  in  the  larynx 
above  the  mucus  and  pus.  By  vomiting  a  much  larger  quantity  is 
expectorated  than  by  the  cough.  Frequently  small  portions  of 
pseudo-membrane  are  expectorated  with  the  mucus  and  pus,  and 
occasionally  also  larger  masses,  complete  moulds,  indeed,  of  the 
larynx,  trachea,  or  even  of  the  bronchial  tubes. 

The  respiration  is  accelerated,  but  not  so  much  as  in  pneumonia 
or  capillary  bronchitis.  In  the  advanced  stage  it  commonly 
becomes  slower  than  at  first.  As  the  obstruction  in  the  larynx 
increases,  the  respiration  assumes  more  and  more  the  character 
which  has  been  designated  abdominal ;  the  infra-mammary  region 
is  depressed  in  each  inspiratory  act,  while  the  larynx  approaches 
the  sternum,  and  the  alse  nasi  are  dilated.  Patients  sometimes 
have  painful  attacks  of  dyspnoea,  due  to  detachment  of  an  edge 
of  the  pseudo-membrane,  and  its  doubling  upon  itself.  In  the 
paroxysm,  the  sufterer  throws  himself  from  side  to  side  in  the 
bed,  or  reaches  his  arms  to  his  mother  or  nurse  for  relief;  his 
eyes  are  wild,  features  anxious,  and,  in  severe  paroxysms,  fingers 


SYMPTOMS.  463 

and  prolabia  livid.     In  the  interval  there  is  comparative  quietude, 
though  the  respiration  is  constantly  embarrassed. 

Tiie  frequency  of  the  pulse  varies  according  to  the  extent  of  the 
inflammation  and  the  stage  of  the  disease.  In  the  commencement 
of  primary  croup  it  ordinarily  varies  from  about  one  hundred  and 
ten  to  one  hundred  and  twenty  beats  per  minute.  In  the  course  of 
the  disease  it  becomes  more  frequent,  and  towards  the  close  of  life 
feeble. 

Now  and  then  a  patient  presents  a  decided  remission  in  symp- 
toms, due  to  detachment  of  the  adventitious  layer,  and  the  friends 
are  apt  to  think  that  the  danger  is  passed.  Unfortunately  the  lull 
in  symptoms  is  in  most  cases  deceitful,  as  the  cause  of  the  dyspnoea 
is  rapidly  reproduced.  I  once  attended  a  case  in  which  there  had 
been  such  dyspnoea  that  an  unfavorable  prognosis  was  given. 
An  almost  complete  intermission,  however,  occurred  in  the  symp- 
toms, with  the  exception  of  the  febrile  movement,  so  that  a  physi- 
cian who  visited  the  patient  at  this  time  diagnosticated  an  essential 
fever.  In  a  few  hours,  the  pseudo-membrane  being  reproduced, 
the  symptoms  returned  with  greater  violence  than  ever,  and  the 
child  died.  So  complete  an  intermission  seldom  occurs  in  a  fatal 
case  ;  and  in  most  patients,  during  the  times  of  temporary  im- 
provement, there  is  still  such  dyspnoea,  with  the  characteristic 
cough,  that  the  nature  of  the  disease  is  apparent. 

If  the  stethoscope  is  applied  over  the  larynx  in  true  croup,  the 
loud  expiratory  as  well  as  inspiratory  sound  is  heard  as  the  air 
passes  by  the  obstruction.  This  sound  is  often  transmitted  to 
every  part  of  the  chest,  so  as  to  obscure  the  rales  which  may  be 
produced  there.  Auscultation  over  the  chest  reveals  either  the 
vesicular  murmur,  perhaps  somewhat  diminished  in  intensity,  or 
more  frequently  the  sonorous  and  afterwards  moist  rales  due  to 
coexisting  bronchitis.  In  a  limited  number  of  cases,  dulness  on 
percussion  is  observed  at  some  part  of  the  chest,  with  bronchial 
respiration,  indicating  pneumonia.  Recovery  from  croup  is  in 
most  patients  gradual ;  the  voice  becomes  less  hoarse,  the  cough 
looser,  and  the  dyspnoea  ceases  by  degrees.  The  structural  changes 
which  have  occurred  in  the  mucous  membrane  of  the  larynx  do 
not  disappear  till  several  days  after  the  last  pseudo-membrane  is 
detached. 

Fatal  cases  may  terminate  in  two  or  three  days,  but  their  ordi- 
nary duration  is  from  five  to  fourteen  days.  Death  may  result 
directly  from  the  thickness  and  firmness  of  the  pseudo-membrane, 
which  obstructs  the  entrance  of  air.     Sudden  death  in  a  paroxysm 


464  PSEUDO-MEMBRANOUS    LARYNGITIS. 

of  dyspnoea  may  occur  from  the  detachment  of  one  end  of  the 
i:)seudo-membrane,  and  its  folding  ujDon  itself.  In  many  patients, 
death  is  not  due  so  much  to  obstruction  to  the  entrance  of  air  from 
the  presence  of  the  pseudo-membrane,  as  to  the  mucus  and  pus 
which  collect  in  the  trachea  and  bronchial  tubes,  and  which  are 
not  expectorated  on  account  of  the  presence  of  the  pseudo-mem- 
brane and  the  feeble  expiratory  efforts  of  the  child.  In  a  case 
which  was  examined  after  death  in  the  Nursery  and  Child's  Hos- 
pital of  this  city,  the  false  membrane  was  apparently  not  sufficient 
to  produce  a  fatal  result,  but  the  air-passages  below  it  were  nearlj'^ 
filled  with  muco-purulent  matter,  which  obstructed  the  entrance  of 
air. 

Pathological  Characters. — This  disease  is  then  essentially  a 
laryngitis  presenting  the  lesions  of  a  simple  though  usually  severe 
mucous  inflammation,  but  with  a  superadded  element,  namely,  the 
false  membrane.  The  coexistence  of  simple  or  pseudo-membranous 
pharyngitis,  tracheitis,  and  bronchitis  is  also,  as  we  have  seen, 
common.  The  impediment  to  respiration,  which  renders  croup  so 
dangerous  and  fatal,  is  due  not  only  to  the  presence  of  the  false 
membrane,  but  to  the  mucus  and  pus  which  collect  below  it,  and 
also  to  the  inflammatory  swelling  of  the  mucous  membrane  and 
submucous  oedema.  In  addition,  there  is  a  neuropathic  element 
which  increases  the  dyspnoea,  and  which  most  observers  consider  a 
spasmodic  contraction  of  the  laryngeal  muscles  induced  by  the  in- 
flammation, and  hence  the  easier  breathing  in  sleep,  and  in  the 
general  muscular  relaxation,  which  precedes  death.  Prof.  Jacobi 
{Amer.  Journ.  of  Obstet.jetc.,!^.  Y.,  May,  1868),  however,  holds  that 
the  state  of  these  muscles  is  one  of  paralysis  rather  than  S2:)asmodic 
contraction.  In  his  opinion,  this  paralysis  "  is  secondary.  It  de- 
pends on  the  oedematous  soaking  of  the  posterior  crico-arytenoid 
muscles  following  the  oedema  of  the  mucous  membrane  of  the 
crico-arytenoid  folds." 

In  several  fatal  cases  which  I  have  had  an  opportunity  to  exam- 
ine after  death,  I  have  found  the  ajipearance  of  the  lungs  quite 
uniform.  They  were  reduced  in  volume  (semi-collapsed)  and  more 
or  less  congested.  Certain  parts  distant  from  the  bronchi,  espe- 
cially the  edges  and  thin  portions,  were  collapsed  completely,  and 
certain  lobules  also  hepatized.  I  have  also  observed,  though  in 
some  of  the  cases  my  attention  was  not  directed  to  it,  distension 
of  the  right  cavities  of  the  heart  with  blood,  and  large  thrombi. 
From  the  nature  of  the  disease,  the  blood  is  less  oxygenated,  and 


I 


DIAGNOSIS  —  PROGNOSIS.  465 

somewhat  darker  than  in  those  who  die  of  diseases  not  involving 
the  respiratory  apparatns. 

Diagnosis. — The  diagnosis  of  true  croup  is  ordinarily  easy.  It 
might  be  mistaken  for  spasmodic  laryngitis,  but  more  frequently 
spasmodic  laryngitis  is  mistaken  for  it.  The  differences  whicli 
will  aid  in  differential  diagnosis  are  the  following :  commencement 
abrupt  and  at  night  in  one,  gradual  in  the  other ;  presence  in  one, 
absence  in  the  other,  of  a  pseudo-membrane  upon  the  surface  of  the 
fauces  ;  fragments  of  this  membrane  in  the  sputum  in  one  ;  charac- 
ter of  the  cough  ;  course  of  the  disease  growing  gradually  worse 
in  one,  in  the  other,  with  few  exceptions,  rapidly  improving.  Trous- 
seau speaks  of  the  liability  to  error  of  diagnosis  in  those  cases  in 
which  spasmodic  laryngitis  is  associated  with  pseudo-membranous 
pharyngitis.  Few  physicians  hesitate  to  designate  as  true  croup 
those  cases  in  which  there  is  a  croupal  cough  in  connection  with 
false  membrane  upon  the  surface  of  the  fauces,  and  yet  the  laryn- 
gitis under  such  circumstances  may  be  merely  spasmodic.  This 
coexistence  of  pseudo-membranous  pharyngeal  and  of  spasmodic 
laryngeal  inflammation  is,  however,  probably  rare,  but  its  occa- 
sional occurrence  should  be  borne  in  mind. 

True  croup  is  readily  distinguished  from  laryngismus  stridulus, 
or  internal  convulsions.  Laryngismus  stridulus  is  a  purely  nerv- 
ous affection ;  it  occurs  suddenly,  causing  great  dyspnoea,  or  momen- 
tary suspension  of  respiration,  without  the  fever  and  without  the 
hoarse  voice  and  cough  of  croup.  When  muscular  relaxation  oc- 
curs, the  attack  ceases.  The  difference  between  the  two  diseases  is 
therefore  obvious. 

Prognosis. — The  great  mortality  from  true  croup  is  universally 
known,  and  those  physicians  who  report  a  large  number  of  favor- 
able cases  have  probably  mistaken  spasmodic  croup  for  this  disease. 
According  to  the  statistics  of  Dr.  "Ware,  nineteen  out  of  twenty 
die;  but  with  judicious  treatment,  commenced  early,  the  mortality 
is  probably  less  than  this,  though  still  great.  Increase  of  dyspnoea, 
the  voice  and  cough  becoming  more  hoarse,  and  the  pulse  more 
accelerated,  indicate  a  fatal  form  of  the  disease.  Attention  has 
already  been  called  to  temporary  improvements  which  are  apt  to 
occur  in  croup,  and  lead  to  an  error  in  prognosis.  However,  im- 
provement continuing  more  than  twelve  hours  is  evidence  of  the 
decline  of  the  disease. 

The  near  approach  of  death  is  shown  by  lividity  with  great  rest- 
lessness, or  by  pallor  and  somnolence.     If  the  patient  recover  from 
croup,  there  often  remains  more  or  less  bronchitis  or  broncho-pneu- 
80 


466  PSEUDO-MEMBEANOUS    LARYNGITIS. 

monia,  which  requires  treatment,  and  the  laryngitis  when  its 
pseudo-memhranoiis  character  is  lost,  persists  for  a  time,  causing 
more  or  less  hoarseness  and  acceleration  of  pulse. 

Treatment. — The  importance  of  early  treatment  in  this  disease 
has  been  sufficiently  alluded  to.  If  it  has  continued  two  or  three 
days  when  first  recognized,  the  chance  of  recovery  is  greatly  dimin- 
ished. As  the  danger  in  true  croup  arises  from  the  presence  of  the 
pseudo-membrane,  the  indication  is  to  prevent  its  formation,  so  far 
as  possible,  and  to  aid  in  its  removal  when  formed. 

Emetics  have  been  and  are  still  much  prescribed  in  the  treatment 
of  this  disease.  Properly  employed,  they  produce  a  good  effect, 
but  much  harm  has  been  done  by  their  injudicious  administration. 
As  a  rule,  the  depressing  emetics  should  not  be  given  except  at  the 
comlhencement  of  the  disease,  not  later,  indeed,  than  the  second 
day,  and  not  given  at  all  if  the  patient  is  feeble  or  cachectic,  or  if 
the  croup  is  secondary,  as  when  it  occurs  in  connection  with 
measles  or  diphtheria.  I  have  known  death  occur  almost  imme- 
diately after  the  administration  of  an  antimonial  emetic  in  the 
pseudo-membranous  larjmgitis  accompanying  diphtheria,  when 
there  was  no  urgent  dyspnoea. 

At  the  commencement  of  croup,  ipecacuanha  or  tartrate  of 
antimony  and  potassa  may  then  be  prescribed  if  the  disease  is 
primary,  and  the  patient  in  good  general  condition  ;  but  if  it  is 
secondary,  or  the  vital  powers  at  all  reduced,  an  emetic  which  is 
less  depressing  is  preferable,  as  turpeth  mineral  or  sulphate  of  copper. 
The  emetic  promotes  the  secretion  of  mucus,  and  a  considerable 
quantity  of  this  substance  is  usually  found  in  the  vomited  matter, 
and  it  may  also  cause  the  detachment  and  expulsion  of  the  softer 
portions  of  the  pseudo-membrane.  If  the  child  in  the  initial  stage 
of  croup  is  under  the  age  of  three  years,  the  syrup  of  ipecacuanha, 
with  or  without  alum,  may  be  administered  in  teasiwonful  doses 
at  intervals  of  ten  or  fifteen  minutes  till  the  emetic  effect  is  pro- 
duced, or  if  the  age  is  above  three  years,  the  compound  syrup  of 
squills  may  be  emploj-ed  instead.  But  when  assured  that  a  pseudo- 
membrane  is  forming,  I  prefer  in  most  cases  the  sulphate  of  copper 
in  one  or  two  grain  doses  given  in  powder  with  an  equal  quantity 
of  ipecacuanha,  and  repeated  in  ten  minutes  if  the  first  dose  does 
not  produce  the  desired  emetic  effect.  There  is  in  most  cases  more 
or  less  relief  of  the  symptoms  after  the  emesis,  though  it  may  be 
but  temporar}'.  In  one  case  recently  in  my  practice,  in  which  there 
was  at  the  first  visit  considerable  dyspnoea,  distinct  croupy  cough, 
and  a  pseudo-membrane  on  both  sides  of  the  fauces,  and  in  wliieh 


TREATMENT.  467 

I  liad  made  an  unfavorable  prognosis,  the  parents  observing  the 
good  effect  of  the  first  powder,  repeated  the  medicine,  contrary  to 
directions,  at  intervals  of  about  two  hours,  till  my  visit  on  tlie 
following  day,  and  the  patient  recovered.  Two  or  three  powders 
are,  however,  ordinarily  sufficient  for  this  preliminary  treatment. 
Turpcth  mineral  is  not  inferior  in  its  effects  to  sulphate  of  copper, 
and  many  physicians  of  ample  experience  prefer  it,  given  in  doses 
of  two  or  three  grains.  Prof.  Fordyce  Barker,  of  this  city,  who 
prescribes  an  emetic  of  turpcth  mineral  immediately  on  being 
summoned  to  a  case,  states  that  he  has  not  lost  a  patient  thus 
treated  for  many  years.  After  prompt  and  efficient  emesis  is  pro- 
duced, other  measures  are  required.  We  will  speak  hereafter  of 
the  further  employment  of  emetics  during  the  progress  of  croup. 
Loss  of  blood  is  not  required  in  the  treatment  of  croup.  The 
stronger  cardiac  sedatives,  as  aconite  and  veratrum  viride,  may 
occasionally  be  advantageously  employed  on  the  first  and  second 
days  of  primary  croup.  They  should  only  be  administered  to 
those  that  are  robust.  They  should  not  be  prescribed  after  the 
pseudo-membrane  is  fully  formed,  nor  in  cases  of  secondary  croup. 
Unfortunately  the  emetic  treatment  recommended  above,  and 
which  must  be  considered  preliminary,  fails  to  arrest  the  disease 
in  a  large  proportion  of  cases.  It  does  seem  to  diminish  the 
amount  of  false  membrane  in  certain  cases,  and  there  is  reason  to 
think  that  it  may  even  in  some  instances  prevent  its  formation, 
so  that  the  inflammation  remains  a  simple  laryngitis,  though  pre- 
senting in  its  commencement  the  characteristic  symptoms  of  croup; 
but  in  other  and  a  large  proportion  of  cases  the  pseudo-membrane 
becomes  fully  formed,  and  continues  to  increase.  The  profession  have 
been  long  looking  for  a  remedy  wdiich,  taken  internally,  ma}^  by  its 
effect  upon  the  blood  or  the  inflamed  surface,  prevent  or  diminish 
the  membranous  formation,  and  also  for  a  remedy  which,  employed 
topically,  may  liquefy  and  remove  it.  The  remedy  which  has  been 
and  still  is  most  frequently  prescribed  for  the  first  of  these  purposes 
is  calomel.  The  ordinary  ill-effects  of  this  agent,  namely,  stomatitis 
and  ptyalism,  should  not  deter  from  its  employment  if  it  exerts  any 
controlling  influence  over  a  disease  so  rapid  and  fatal  as  true  croup. 
I  am  of  opinion  that  it  is  useful  unless  there  is  that  degree  of 
impoverishment  of  the  blood  and  cachexia  which  would  contra- 
indicate  the  continued  use  of  any  depressing  agent.  Calomel 
probably  has  no  effect  upon  the  false  membrane ;  but  it  is  to  be  recol- 
lected that  there  are  other  factors  in  the  production  of  the  dyspnoea 
which  it  is  probable  that  calomel  does  aid  in  removing,  whether 


468  PSEUDO-MEMBRAXOTJS    LARYNGITIS. 

by  its  derivative  effect  on  the  intestinal  surface,  or  by  some  other 
mode  of  action  not  fully  understood.  Calomel  is  believed  to  be  one 
of  the  most  efficient  agents,  administered  internally,  for  removing 
the  thickening  and  infiltration  of  the  laryngeal  mucous  membrane 
and  the  submucous  oedema.  I  think  that  I  have  observed  benefit 
from  its  employment,  whether  in  a  single  dose  of  six  to  ten  grains,  or 
in  small  doses  of  one-fourth  to  one  grain  repeated  several  times  in 
twenty -four  hours.  The  calomel  may  be  administered  alone,  or  with 
ipecacuanha  not  in  sufficient  quantity  to  cause  emesis,  or  in  certain 
cases  with  Dover's  powder.  It  may  be  given  from  two  to  four 
days,  perhaps  sometimes  longer,  when  it  should  be  followed  by  a 
mixture  of  chlorate  of  potassa  or  soda  and  muriate  of  ammonia 
given  frequently.  In  cases  in  which  the  vital  powers  are  reduced, 
especially  in  secondary  croup,  this  mixture  should  be  given  from  the 
first,  in  place  of  calomel.  The  chlorate  has  a  solvent  effect,  though 
feeble,  on  pseudo-membranes,  and  as  when  taken  into  the  system  it  is 
known  to  be  eliminated  in  most  of  the  secretions  and  excretions, 
it  is  not  improbable  that  it  escapes  also  from  the  surface  of  the 
larynx  in  the  mucus,  and  therefore  comes  in  contact  with  the  mem- 
branous formation.  The  chlorates  in  frequent  large  doses  some- 
times cause  salivation.  Probably  the  eflect  of  the  muriate  is 
subordinate,  but  it  is  believed  by  therapeutists  to  increase  the  muco- 
purulent secretion,  and  therefore  diminish  in  some  degree  the 
turgescence  of  the  mucous  membrane.  Cases  in  which  there  is 
marked  and  protracted  dyspnoea  and  croupal  cough  do  now  and 
then  recover  with  the  use  of  chlorate  of  potassa  or  soda  and  mu- 
riate of  ammonia,  either  employed  after  calomel,  or  without  it  as 
the  main  remedy  from  the  commencement  of  the  disease — so  many, 
indeed,  that  it  cannot  be  doubted  that  they  do  have  some  curative 
effect.  The  following  formula  may  be  employed  for  a  child  from 
three  to  five  years  of  age : — 

R.  Potas.  chlorat.  3j  ; 
Amnion,  muriat.  ^ij  ; 
Syr.  simplic.  5J  ; 
Aquae  §ij.     Misce. 

Dose,  one  to  two  teaspoonfuls  every  half  hour  or  hourly,  accord- 
ing to  the  urgency  of  the  symptoms.  This  should  be  continued 
regularly  night  and  day  until  the  cough  becomes  looser,  or  until  it 
is  evident  from  the  unfavorable  nature  of  the  case  that  it  can  be 
of  no  further  service. 

A  very  important  part  of  the  treatment  is  the  inhalation  of 
steam.      Some  of  our  most  experienced  physicians  consider  this 


TREATMENT.  469 

more  useful  than  all  otlier  measures  combined.  In  one  of  the  most 
severe  cases  which  I  have  met,  which  terminated  favorably,  the 
room  was  so  filled  with  steam  that  water  hung  in  drops  from  the 
ceiling.  The  atmosphere  which  the  child  breathes  should  be  con- 
stantly loaded  with  moisture,  without,  however,  that  degree  of 
heat  which  would  add  materially  to  the  discomfort  of  the  patient 
or  attendants.  Moist  warm  air  coming  in  contact  with  the  in- 
flamed surface  promotes  expectoration  and  renders  the  cough 
looser.  Steam  may  be  readily  produced  by  placing  heated  irons 
or  bricks  in  a  shallow  pan  or  pail  containing  a  little  water,  by 
pouring  water  upon  a  heated  surface,  or  by  a  spirit-lamp  or  gas- 
jet  under  a  pan  of  water.  In  order  to  avoid  heating  the  entire 
room  and  to  concentrate  the  vapor,  the  nurse  may  sit  with  the 
child  under  a  frame  covered  with  a  blanket,  and  the  steam  be  pro- 
duced underneath. 

A  temperature  of  75°  or  80°,  if  the  atmosphere  is  loaded  with 
moisture,  is  more  readily  tolerated  than  a  lower  temperature  with 
a  dry  atmosphere,  and  a  temperature  at  least  as  high  as  75°  is 
required,  or  too  much  of  the  vapor  is  deposited.  Of  late,  the  in- 
halation of  the  spray  of  lime-water  has  been  recommended,  in  the 
belief  that  it  exerts  a  solvent  effect  upon  the  false  membrane. 
The  atomizer  has  been  employed  in  order  to  produce  the  spray, 
but  difficulty  attends  its  use  for  children.  It  has  been  still  more 
recently  recommended  to  add  to  the  water  which  is  employed  for 
the  purpose  of  producing  steam  one  or  two  lumps  of  quicklime, 
and  allowing  them  to  slake.  The  vapor  by  this  means  becomes 
impregnated  with  particles  of  lime.  This  last  mode  of  employing 
lime  may  partially  obviate  the  principal  objection  which  has  been 
raised  against  the  use  of  steam  in  the  treatment  of  croup,  namely, 
that  it  necessitates  confining  the  air,  which  soon  becomes  loaded 
with  carbonic  acid,  since  slaked  lime,  when  moistened,  rapidly 
absorbs  this  gas. 

The  employment  of  lime  by  inhalation  in  this  disease  certainly 
merits  further  trial,  although,  in  the  few  cases  in  which  I  have 
employed  it  in  both  the  ways  stated  above,  I  have  observed  no 
decided  benefit  from  its  use. 

It  has  already  been  stated  that  depressing  emetics  should  not 
be  employed  after  the  second  day,  but  a  period  arrives  in  most  cases 
when  another  class  of  emetics  are  required.  They  are  required 
when  the  dyspnoea  is  urgent,  as  a  means  of  removing  from  the  air- 
passages  the  collection  of  mucus  and  pus  and  portions  of  false 
membrane  which  may  be  detached.     Those  emetics  should  now  be 


470  PSEUDO-MEMBRANOUS    LARYNGITIS. 

prescribed  which  operate  promptly  with  the  least  depression. 
Sulphate  of  copper  is  one  of  the  best,  if  not  the  best,  for  this  stage 
of  croup,  and  it  is  usually  employed  by  physicians.  A  child  of 
five  years  may  take  one  grain  dissolved  in  a  little  water,  and  the 
dose  be  repeated  if  required  in  ten  minutes.  Sulphate  of  zinc  or 
turpeth  mineral  may  be  used  in  the  place  of  the  copper.  Dr.  J, 
F.  Meigs,  of  Philadelphia,  prefers  pulverized  alum  given  in  tea- 
spoonful  doses,  but  it  is  less  efiicient,  and  I  am  not  aware  that  it 
possesses  any  advantages  over  the  sulphate  of  copper.  "Whatever 
emetic  is  employed,  its  operation  may  be  promoted  by  draughts  of 
warm  water. 

It  is  to  be  recollected  in  the  treatment  of  croup  that  the  pseudo- 
membrane,  by  commencing  decomposition,  and  by  the  pus  and 
mucus  which  collect  underneath,  is  more  easily  detached  after  a 
few  days,  if  the  patient  lives,  than  at  first.     Therefore  the  phy- 
sician should  endeavor  to  sustain  the  vital  powers,  in  order  that 
the  cough  may  have  sufiicient  force  to  separate  this  substance  as 
soon  as  its  fibres  of  attachment  begin  to  loosen.     A  patient  with 
croup  rarely  takes  solid  food,  but  he  should  be  allowed  beef-tea, 
milk,  and  farinaceous  drinks  at  short  intervals.     If  there  are  signs 
of  exhaustion,  alcoholic  stimulants  are  proper,  and  fresh  air  should 
also  be  allowed  so  far  as  is  compatible  with  the  inhalation  of  steam. 
"While   these   general   measures  are  employed,  local  treatment 
should  not  be  neglected.     The  profession  are  not  agreed  as  to  the 
treatment  either  external  or  internal  of  the  throat.     As  to  external 
treatment,  some  recommend  poultices,  others  cold  applications,  and 
others  still,  irritants.     Professor  Peaslee,  of  this  city,  in  a  series  of 
•  papers   on   the   pathology  of  croup,   published   in   the  American 
Medical  Ifonthli/,  1854,  says  of  cold  applied  externally:  "We  con- 
sider this  of  the  greatest  value  and  importance.   If  cold  applications 
are  efiicacious   in  all   cases   of  external   inflammation,   they   are 
scarcely  less  so  here,  where  the  inflamed  surface  is  so  nearly  super- 
ficial.    Cold  must,  however,  be  continuously  applied  to  produce 
the  desired  effect.     Applied  at  intervals,  indeed,  it  rather  promotes 
than  retards  the  inflammatory  process ;  since  during  the  intervals  the 
temperature  rises  above  the  norrnal  standard,  in  consequence  of  the 
reaction  of  the  chill  on  the  surface.    Cold  water  may  be  constantly 
dropped  from  a  sponge  upon  a  compress  laid  over  the  throat  of  the 
child;  and  the  latter  should  be  of  only  one  or  two  thicknesses  of 
linen,  that  evaporation  may  go  on  as  rapidly  as  possible." 

In  ordinary  cases  cold  applied  over  the  larynx  is  preferable  to 
poultices  or  warm  applications.     The  sides  of  the  neck  should  be 


TREATMENT.  471 

kept  warm  by  pieces  of  pork,  or  one  or  two  tliickiiesses  of  ilanucl, 
while  in  the  interspace  in  front,  over  the  larynx,  a  compress  of 
muslin  or  linen  squeezed  from  ice-water  should  be  applied  every 
five  or  ten  minutes.  These  may  be  retained  in  place  by  a  single 
thickness  of  muslin  passing  around  the  neck,  and  cut  narrow  in 
front,  in  order  to  facilitate  the  applications  of  the  compress.  In 
place  of  the  compress,  a  small  quantity  of  crushed  ice  may  be  em- 
ployed, surrounded  by  oil-silk  to  prevent  dripping.  This  mode  of 
applying  cold  I  have  found  to  be  more  convenient,  on  account  of 
the  frequent  restlessness  of  the  child,  than  that  recommended  by 
Prof.  Peaslee.  Cold  is  especially  serviceable  if  the  child  is  robust, 
with  flushed  cheeks  and  full  and  rapid  pulse.  In  secondary  croup, 
or  croup  occurring  in  feeble  states  of  system,  or  presenting  a  sub- 
acute character,  poultices  or  fomentations  to  the  neck,  with  mode- 
rate irritation,  may  sometimes  give  most  relief. 

Topical  treatment  of  the  fauces  and  larynx  has  long  been  re- 
commended in  croup,  and  the  agent  Avhicli  has  been  most  fre- 
quently applied  is  nitrate  of  silver  in  solutions  varying  in  strength 
from  ten  to  forty  grains  to  the  ounce.  It  is  applied  once,  twice, 
or  several  times  daily.  JSTitrate  of  silver  does  not  dissolve  the 
pseudo-membranes,  but  it  contracts  those  with  which  it  comes  in 
contact,  and  by  the  contraction  aids  in  their  detachment. 

Great  difficulty,  however,  attends  the  application  of  the  probang 
to  the  larynx  of  the  child,  on  account  of  his  struggles  and  resist- 
ance, and  it  may  well  be  doubted  whether  the  most  skilful  opera- 
tors usually  succeed  in  applying  it  to  the  interior  of  this  organ. 
But  if  the  instrument  is  pressed  against  the  aperture  of  the  glottis, 
some  of  the  liquid  trickles  from  the  sponge  into  the  larynx,  as  is 
indicated  by  the  severe  coughing  which  it  produces.  Of  late  years 
three  other  substances  have  been  used  for  topical  treatment  of  the 
throat,  which  appear  to  be  more  effectual  in  removing  the  pseudo- 
membrane  and  controlling  the  inflammation.  One  is  liquor  ferri 
subsulphatis,  another  carbolic  acid,  and  the  third  bromine.  The 
liquor  ferri  subsulphatis  is  best  employed  with  glycerine  in  the 
proportion  of  one  part  to  four. 

B,  Liq.  ferri  subsulphatis  5j ; 
Glycerinse  ^ss.     Misce. 

Carbolic  acid,  in  its  crystalline  or  undiluted  state,  is  an  active 

caustic,  with  a  tendency  to  spread.     It  should  be  used  considerably 

diluted  with  water. 

R.  Acid,  carbolic.  f5ss; 
Aquae  gv.     Misce. 


472  PSEITDO-MEMBEAKOUS    LARYNGITIS. 

Bromine  has  only  recently  been  employed  for  topical  treatment 
of  pseudo-membranous  inflammations.  It  is  used  in  conjunction 
with  bromide  of  potassium. 

IJ;.  Bromiuii  gij ; 

Potass,  bromid.  gr.  xiv; 
Aqufe  3j.     Misce. 

This  is  called  the  bromine  solution,  but  it  must  be  considerably 
diluted  for  use.  Twenty-four  to  forty  drops  should  be  added  to 
an  ounce  of  water  for  application  to  the  fauces  or  larynx.  There 
are  physicians  who  highly  extol  each  of  these  three  agents  in  the 
treatment  of  croup  as  well  as  diphtheria.  They  are  probably  all 
useful,  though  I  cannot  speak  from  personal  observation  in  refer- 
ence to  the  efl:ect  of  bromine.  They  should  be  applied  in  the  same 
manner  as  nitrate  of  silver,  to  which  either  one  is  probably  prefer- 
able. Of  the  three  agents,  the  one  which  I  can  highly  recommend 
from  personal  experience  for  those  cases  which  require  this  mode 
of  treatment,  is  the  subsulphate  of  iron.  Local  treatment,  as  re- 
commended above,  is  obviously  most  useful  in  those  cases  in  which 
there  is  decided  inflammation  of  the  faucial  surface  attended  with 
patches  of  false  membrane,  or  those  cases  in  which  the  inflamma- 
tion is  first  pharyngeal  and  becomes  laryngeal  by  extension. 

Unfortunately,  as  I  have  already  stated,  true  croup,  whatever 
the  therapeutic  treatment,  is,  in  a  large  proportion  of  cases,  a  pro- 
gressive disease.  The  hoarseness  of  the  cough  and  voice  and  the 
dyspnoea  gradually  increase.  The  pulse,  becoming  more  frequent 
and  feeble,  indicates  the  need  of  the  most  nutritious  food,  as  the 
animal  broths,  and  of  alcoholic  stimulants.  The  danger  is,  how- 
ever, from  the  dyspnoea  rather  than  asthenia.  Medicine  has  failed 
to  check  the  disease,  and  shall  now  the  expedients  of  surgery  be 
tried — shall  tracheotomy  be  performed  ? 

The  published  statistics  relating  to  tracheotomy  in  croup  are  to 
a  considerable  extent  unsatisfactory,  since  we  are  not  informed,  as 
regards  most  of  them,  at  what  stage  of  the  disease  the  operation 
was  performed,  and  what  were  the  evidences  of  a  fibrinous  exuda- 
tion. The  most  valuable  and  reliable  statistics  bearing  upon  this 
subject,  so  far  as  I  am  aware,  are  those  published  by  Prof.  Jacobi, 
of  this  city,  in  the  American  Journal  of  Obstetrics,  etc.,  for  May, 
1868,  and  containing  the  results  of  the  cases  which  were  operated 
on  by  himself  and  Drs.  Krackowizer  and  Voss.  These  gentlemen 
are  known  to  the  profession  of  Xew  York  as  careful  and  judicious 
practitioners,  not  likely  to  operate  when  there  was  probability  of 
success  by  therapeutic  measures,  and  not  likely  to  mistake  simple 


TREATMENT. 


473 


or  spasmodic  laryngitis  for  true  croup, 
tistics  of  their  operations : — 


I  have  tabulated  the  sta- 


Age. 

Under  2  years 
From  2  to  3  years 
"     3  to  4     " 
"    4  to  5     " 
"     5  to  G     " 
"     Gto7     " 
"     7  to  8     " 
10     " 
Not  given 


Number. 

Recovered. 

Died 

8 

1 

7 

29 

5 

24 

26 

4 

23 

34 

11 

23 

9 

2 

7 

1 

1 

0 

3 

0 

8 

1 

0 

1 

55 

15 

40 

1G6 


39 


127 


Time  of  death  after 
operatiou. 

Within  24  hours 
On  2d  day 

"  3d    " 

"  4th  " 


Total 


Number  of  Time  of  Death  after 

cases.  operation. 

19  On  5th  day 

7  "    Gth    " 

16  "    7th    " 

15  "    9th    " 

From  10th  to  31st  day 


Number  of 
cases. 

9 

4 

2 
1 
5 

78 


The  following  were  the  causes  of  death,  as  given  in  the  records 


of  73  cases : — 

In  operation 

Apnoea  from  too  late  operation 

Apnoja        .... 

Anfemia  and  exhaustion     . 

Diphtheria  .        .         . 

Bronchitis 

Broncho-pneumonia  . 


1 
6 
3 
4 
8 
6 
15 


Pneumonia           ....  5 
Broncho-pneumo,  &  pulm.  gangrene  1 

Pulmonary  oedema      ...  1 

Pseudo-membranous  bronchitis  18 

Tuberculosis        ....  1 

Convulsions          ....  2 

Emphysema          ....  2 


Total 


73 


The  following  table  gives  the  result  of  tracheotomy  in  one  hun- 
dred cases.  It  is  prepared  from  the  statistics  of  Giiterbach,  lately 
published : — 


Age. 

Under  1  year. 
Between  1  and  2  years 

"        2  and  3     " 

"        3  and  4 

"        4  and  5 

"        5  and  6 

"        6  and  8 

"        8  and  9 

From  conversations  whic 


Result. 

1  case  fatal 

33|  per  cent,  recovered. 

40 

38^3 

44| 

14f 

25 


1  I  have  had  with  surgeons  of  ISTew 
York,  I  am  persuaded  that  the  above  tables  present  a  more  favor- 


474  PSEUDO-MEMBRANOUS    LARYNGITIS. 

able  result  than  could  be  furnished  by  the  general  surgical  practice 
of  this  city.  Most  I^ew  York  surgeons,  however,  seem  to  shun  the 
operation  and  regard  it  with  ill-favor,  and  did  they  operate  as  fre- 
quently as  those  whose  names  I  have  mentioned,  possibly  the  re- 
sult would  be  better.  Statistics  in  Paris  probably  give  nearly  the 
true  proportion  of  successful  and  unsuccessful  operations  of  tra- 
cheotomy for  croup,  as  it  is  performed  by  skilful  and  careful  sur- 
geons. Of  388  cases  occurring  in  the  practice  of  several  Parisian 
surgeons,  346  died  and  42  recovered;  while  in  the  Hopital  Sainte 
Eugenie,  of  374  operated  on,  310  died.     (Bouchut.) 

The  facts  in  reference  to  tracheotomy  in  croup  are  the  following : 
The  majority  of  those  operated  on  do  not  recover,  but  some  live 
who  without  the  operation  would  die.  The  operation  is  now  more 
successfully  performed  than  formerly,  as  the  conditions  of  success- 
ful operation  are  better  understood.  Those  who  have  operated 
several  times,  confess  that  their  last  cases  did  better  than  their 
first.  Trousseau's  experience  was  striking  and  instructive  in  this 
respect.  'No  one,  probably,  ever  performed  this  operation  for  croup 
more  times  than  he,  and,  from  constantly  greater  success,  he  be- 
came more  and  more  an  advocate  of  the  operation.  Tracheotomy, 
if  proi^erly  performed,  does  not  in  any  case  shorten  life,  but  it 
frequently  prolongs  it  several  days.  It  diminishes  greatly  the 
dyspnoea,  and  renders  death  easy. 

The  objections  to  the  operation  are  partly  of  a  moral  nature. 
The  parents,  already  in  the  extreme  of  grief  on  account  of  the 
suiiering  and  probable  death  of  the  child,  consent  with  reluctance 
to  an  operation  which  promises  not  cure,  but  a  prolongation  of  life. 
Common  sympathy  with  the  child  and  regard  for  the  emotions  of 
the  parents  should  certainly  have  an  influence  in  deciding  for  or 
against  the  operation.  The  first  case  of  tracheotomy  which  I 
witnessed  was  such  as,  if  common,  would  condemn  this  operative 
measure  entirely.  No  anaesthetic  was  given,  and,  in  the  midst  of  the 
struggles  of  the  child,  large  veins  were  severed,  from  which  an  abun- 
dant hemorrhage  occurred.  The  trachea  was  opened,  but  this  was 
no  sooner  done  than  death  occurred,  partly  from  the  loss  of  blood, 
and  partly  from  the  obstruction  to  respiration  caused  by  its  entrance 
into  the  bronchial  tubes.  Such  cases  are,  however,  quite  exceptional. 
Death  rarely  occurs  during  the  operation,  unless  the  patient  is  al- 
ready moribund,  and  the  possibility  of  such  a  result  should  have 
little  weight  in  our  decision  for  or  against  the  operation. 

Few  will  deny,  in  the  light  of  statistics,  that  tracheotomy  is, 
in  certain  cases,  proper,  and  that  a  physician  at  times  would  be 


TREATMENT.  475 

culpiil)lc  if  lie  (lid  not  strongly  urge  its  performance.  There  are 
certain  supposed  contraindications.  One  is  age  less  than  two  years. 
It  is  true  that  those  under  the  age  of  two  years  are  less  likely  to 
recover  after  the  operation  than  those  above  that  age;  still,  trache- 
otomy has  now  and  then  saved  the  lives  of  the  youngest  infants 
who  have  croup.  The  possibility,  therefore,  of  success  justifies 
the  performance  of  the  oi)eration,  however  young  the  infant,  when 
the  only  alternative  is  death.  In  the  foregoing  statistics  it  is  seen 
that  one  of  eight  recovered  who  were  under  the  age  of  two  years. 

The  presence  of  capillary  bronchitis  or  pneumonia  does  not  posi- 
tively contraindicate  tracheotomy,  though  it  diminishes  greatly 
the  chances  of  a  favorable  issue.  N"or  is  tracheotomy  forbidden 
by  the  extension  of  the  false  membrane  into  the  bronchial  tubes, 
since  it  diminishes  the  amount  of  obstruction  along  which  the  air 
passes  in  or^er  to  reach  the  lungs,  and  the  muco-pus  as  well  as 
pseudo-membrane,  lying  below  the  point  of  operation,  may  be 
expectorated  through  the  aperture.  A  decidedly  asthenic  state, 
as  after  measles  or  scarlet  fever,  indicated  by  feeble  pulse  and  other 
symptoms  of  exhaustion,  may  or  may  not  contraindicate  the  ope- 
ration, whether  the  pseudo-membrane  is  limited  to  the  larynx  and 
trachea  or  is  more  extensive. 

The  manner  of  performing  tracheotomy  and  the  subsequent 
treatment  pertain  to  surgery,  and  are  described  in  surgical  works. 
A  skilful  surgeon  should,  indeed,  be  employed  to  perform  the 
operation  when  it  is  practicable.  At  what  time  in  the  course  of 
the  disease  tracheotomy  should  be  resorted  to  is  an  important 
practical  question.  Trousseau  at  one  time  recommended  it  as 
soon  as  there  were  certain  evidences  of  the  presence  of  a  pseudo- 
membrane,  but  in  the  latter  part  of  his  life  he  did  not  operate  so 
early.  The  correct  rule,  in  my  opinion,  is  not  to  operate  till  there 
are  signs  that  the  blood  is  not  sufficiently  oxygenated,  such  as 
lividity  of  the  prolabia  and  tips  of  fingers.  "When  these  signs 
occur,  it  is  unsafe  to  delay  long.  The  arrangements  should  be  pre- 
viously made,  that  no  time  be  lost. 

It  is  an  interesting  fact  that  a  large  proportion  of  those  who 
die  after  tracheotomy  die  of  bronchitis,  usually  capillary,  or  of 
pneumonia  developed  after  the  operation.  These  diseases  seem  to 
be  partly  attributable  to  the  operation,  or,  if  previously  existing, 
to  be  aggravated  by  it.  It  is  believed  that  the  introduction  into 
the  bronchial  tubes  and  the  lungs  of  cool  air,  of  air  not  warmed  by 
the  natural  circuit  through  the  nostrils  and  larynx,  may  be  a  cause 
of  these  inflammatory  complications.     Sometimes,  also,  the  canula 


476  BRONCHITIS. 

by  pressure  increases  the  inflammation  of  the  surface  on  which  it 
lies.  Therefore,  not  only  does  the  operation  require  skill  in  its 
performance,  but  much  of  its  success  depends  on  the  subsequent 
management.  After  the  operation,  the  temperature  of  the  apart- 
ment should  be  kept  constantly  at  from  85°  to  90°,  and  loaded 
with  m.oisture.  This  obviates  in  part,  but  only  in  part,  the  tendency 
to  bronchitis  and  pneumonia.  Constant  attention  should  be  given 
to  the  canula,  to  prevent  its  filling  with  mucus  and  pus.  Trousseau 
employed  a  double  canula,  which  can  be  readily  cleaned  by  removing 
the  internal  cylinder.  The  nurse,  when  properly  instructed,  can 
remove  this  cylinder  as  often  as  may  be  necessary  in  order  to  clean 
it.  Mr.  Lawrence,  of  London,  and,  following  him,  some  other 
surgeons,  prefer  not  to  use  the  canula.  The  edges  of  the  wound 
are  kei:»t  apart  by  a  wire  which  passes  around  the  neck,  or  a  little 
of  the  trachea  is  removed  so  as  to  produce  a  sufiicient  aperture. 
The  reader  is  referred  for  particulars  regarding  this  mode  of  ope- 
rating to  recent  treatises  on  operative  surgery. 

After  the  operation  no  more  medication  is  required.  The  patient 
should  be  kept  quiet  and  free  from  excitement.  His  diet  should 
be  mainly  liquid,  and  of  the  most  nourishing  character.  In  a  few 
days,  if  the  symptoms  abate,  the  aperture  may  from  time  to  time 
be  closed  with  the  finger  after  the  withdrawal  of  the  canula,  in 
order  to  ascertain  if  the  larynx  is  free  from  obstruction.  If  bron- 
chitis or  broncho-pneumonia  arise,  the  oil-silk  jacket,  with  counter- 
irritation  to  the  chest,  is  required,  and  stimulating  expectorants,  as 
carbonate  of  ammonia  and  syrup  of  senega,  should  be  ordered. 


CHAPTER   IV. 

BRONCHITIS. 

Inflammation  of  the  bronchial  tubes,  or  bronchitis,  is  probably 
the  most  frequent  disease  of  early  life.  It  is  usually  associated 
with  more  or  less  inflammation  of  the  mucous  membrane  of  the 
nostrils,  larynx,  and  trachea.  We  designate  the  disease  coryza, 
laryngitis,  or  bronchitis,  according  as  one  or  the  other  inflamma- 
tion predominates.  Sometimes  bronchitis  occurs  with  but  slight 
inflammation  elsewhere,  and  often  the  coryza  and  laryngitis  abate 
while  the  bronchitis  is  still  active. 


BRONCHITIS.  477 

Bronchitis  occurs  both  as  a  primary  and  secondary  disease.  The 
secondary  form  is  common  in  connection  with  measles,  hooping- 
cough,  pneumonia,  and  pulmonary  j^hthisis,  and  it  is  not  uncom- 
mon in  scarlet  fever,  variola,  remittent  and  continued  fevers. 
Bronchitis  is  mild  or  severe,  and  acute,  subacute,  or  chronic.  If 
the  inflammation  atfccts  the  bronchules,  the  bronchitis  is  called 
capillary.  Bronchitis  is  usually  bilateral,  afiecting  the  tubes  on 
the  two  sides  with  about  equal  intensity.  The  exceptions  are 
when  it  is  dependent  on  pneumonia  or  pulmonary  phthisis.  In 
these  cases  it  is  confined  to  those  tubes,  or  nearly  to  those,  which 
are  surrounded  by  the  tubercular  or  inflammatory  product. 

Causes. — The  causes  of  secondary  bronchitis  are  obviously  the 
diseases  in  connection  with  which  it  occurs.  The  cause  of  primary 
bronchitis  is  the  same  as  that  of  simple  acute  laryngitis  or  coryza, 
namely,  sudden  change  of  temperature  from  warm  to  cold,  exposure 
to  currents  of  air,  the  practice  of  sending  children  without  sufii- 
cient  clothing  from  heated  rooms  into  the  open  air,  the  throwing 
off  of  bedclothes  at  night,  etc.  Dentition  is  also  an  occasional 
cause,  since  some  children  have  attacks  which  coincide  with  the 
eruption  of  the  teeth.  The  cough  of  dentition  is  usually  purely  a 
nervous  afilection ;  but  in  other  instances  it  is  accompanied  by 
more  or  less  mucous  secretion,  and  is  evidently  dependent  on  a 
mild  inflammation. 

Anatomical  Characters. — In  the  most  common  form  of  bron- 
chitis, the  larger  bronchial  tubes  only  are  afliected.  They  are  the 
seat  of  the  inflammation  in  most  of  those  cases  which  are  desig- 
nated "  colds"  by  families,  and  which  are  often  treated  without 
the  aid  of  the  physician.  The  lining  membrane  of  the  bronchial 
tubes  presents  the  ordinary  anatomical  characters  of  mucous  in- 
flammations. It  is  reddened  uniformly  or  in  patches,  intensely,  or 
in  that  milder  degree  known  as  arborescence,  according  to  the 
severity  of  the  inflammation. 

The  secretion  of  the  muciparous  follicles  is  at  first  arrested,  and 
the  surface  of  the  membrane  is  drv.  In  the  course  of  a  dav  or 
two  the  secretor}'  function  is  re-established,  and  the  surface  is 
covered  with  thin  and  transparent  mucus.  A  day  or  two  later,  the 
secretion  becomes  thicker,  consisting  of  mucus  and  pus.  Mixed 
with  these  substances  are  epithelial  cells,  which  are  exfoliated  in 
abundance  from  the  inflamed  surface.  At  the  same  time  the 
mucous  membrane  becomes  thickened  and  more  or  less  softened. 
If  the  inflammation  is  severe,  the  vessels  of  the  submucous  cellular 
tissue  are  also  injected. 


478  BRONCHITIS. 

Usually,  in  about  a  week  in  the  young  child,  in  from  one  to  two 
weeks  in  older  children,  the  inflammation  begins  to  abate.  Gradu- 
ally the  inflamed  membrane  returns  to  its  normal  consistence, 
thickness,  and  vascularity,  and  with  this  return  to  the  healthy 
state  the  muco-purulent  secretion  abates. 

In  this,  which  is  the  simplest  form  of  bronchitis,  and  most  com- 
mon, there  is  no  uk-eration,  and  rarely  any  pseudo-membranous 
formation,  if  the  disease  is  idiopathic.  Pseudo-membranous  bron- 
chitis is  not  unusual  as  an  accompaniment  of  pseudo-membranous 
laryngo-tracheitis. 

Were  bronchitis  limited  to  the  larger  bronchial  tubes,  it  would 
indeed  be  a  simple  aflfection,  but  unfortunatel}^  it  has  a  tendency 
to  extend  downwards.  Commencing  in  the  larger,  it  gradually 
invades  the  smaller  tubes  in  a  similar  manner  to  the  extension  of 
erj'sipelas  upon  the  skin.  More  rarely  the  inflammation  com- 
mences simultaneously  in  the  larger  and  smaller  tubes.  I^ow  the 
gravity  of  bronchitis  is  proportionate  to  the  degree  of  its  exten- 
sion downwards.  It  may  stop  at  any  point  in  its  progress,  but  if 
it  reach  the  smaller  tubes  it  is  one  of  the  most  serious  afliections 
of  early  life,  that  already  alluded  to,  namely,  capillary  bronchitis. 

The  mucous  membrane  of  the  minute  tubes,  those  next  to  the 
air-cells,  is  delicate,  with  but  little  submucous  connective  tissue, 
and  it  frequently,  at  post-mortem  examinations,  does  not  present  to 
the  eye  those  distinct  inflammatory  changes  which  are  observed  in 
tubes  of  large  diameter.  It  is  sometimes  not  notably  thickened, 
nor  its  vascularity  much  increased,  even  when  there  is  reason  to 
believe  from  the  symptoms  that  it  was  the  seat  of  active  phlegmasia. 
As  we  pass  from  these  minute  tubes  to  those  of  larger  calibre,  the 
inflammatory  lesions  become  more  distinct.  The  inflammation 
produces  minute  and  abundant  points  of  redness,  and  the  membrane 
is  evidently  thickened ;  often  it  is  rough  or  granular. 

The  minute  bronchial  tubes  are  very  small,  especially  under 
the  age  of  three  years,  and  since  in  capillary  bronchitis  a  large 
proportion  of  them  are  inflamed,  the  source  of  the  danger  is 
apparent.  It  is  with  difiiculty  that  the  patient  with  capillary 
bronchitis  can,  by  the  efibrt  of  coughing,  free  the  tubes  from  the 
secretions  which  are  constantly  collecting  in  them.  In  weakly 
children,  under  the  age  of  two  years,  expectoration  is  most  difficult, 
and  hence  the  great  and  increasing  dyspnoea  from  which  such 
patients  suflfer. 

In  unfavorable  cases  of  capillary  bronchitis,  the  following  changes 
are  apt  to  occur.    The  small  tubes,  usually  those  in  the  posterior  por- 


ANATOMICAL    CHARACTERS.  479 

tion  of  the  lungs,  become  more  and  more  loaded  with  mucus  and 
pus,  obstructing  the  entrance  of  air  till,  finally,  one  after  another  of 
the  lobules  cease  to  be  inflated.  As  the  air  passes  out  of  the  air-cells 
of  a  lobule  more  readily  than  it  enters  them,  partial  lobular 
collapse  occurs.  Doubtless,  also,  some  of  the  mucus  and  pus,  no 
longer  expectorated,  is  forced  backward  into  the  air-cells.  JSTow,  a. 
portion  of  lung  from  which  air  is  excluded  while  the  circulation 
continues,  becomes  congested.  If  the  lungs  of  a  patient  who  has 
died  at  this  stage  of  capillary  bronchitis  are  examined,  the  ante- 
rior portions  will  be  found  to  present  nearly  their  normal  appear- 
ance, while  the  lobular  changes  which  have  been  described  will 
be  found  mainly  in  the  posterior  part.  Certain  of  the  lobules  will 
be  observed  depressed  below  the  common  level,  of  a  dark  red  color 
from  passive  congestion,  firm  to  the  touch,  and  non-crepitant  or 
feebly  crepitant.  Sometimes  only  a  few  of  the  lobules  have  under-  • 
gone  this  change  of  colkpse  and  congestion,  but  more  frequently  a 
considerable  number  on  both  sides  are  affected. 

Up  to  this  time  there  is  often  no  pneumonia,  but  this  is  the  state 
of  Inngs  and  bronchial  tubes  which  has  sometimes  been  mistaken 
for  and  designated  broncho-pneumonia.  It  has  also  been  called 
lobular  pneumonia.  The  substance  which  fills  the  bronchial  tubes  is 
usually  muco-purulent,but  in  exceptional  cases,  in  addition  to  mucus 
and  pus,  there  is  more  or  less  fibrin.  This  ordinarily  occurs  as  a 
delicate  film  of  small  extent,  observed  here  and  there,  and  readily 
detached  from  the  surface  underneath.  In  rare  instances  it  occurs 
as  a  firm  and  continuous  membrane,  forming  a  mould  of  the  tubes, 
increasing  greatly  the  dyspnoea,  and  constituting  a  true  bronchial 
croup. 

If  the  patient  survive  the  immediate  effects  of  capillary  bron- 
chitis, the  inflammation  of  the  mucous  membrane  soon  begins  to 
abate.  The  collapsed  and  congested  lobules,  and  the  terminal 
portions  of  the  bronchial  tubes  leading  to  them,  which  are  ob- 
structed by  inflammatory  products,  ordinarily  return  to  their  nor- 
mal state  as  the  inflammation  declines,  but  in  other  instances  they 
undergo  changes  which  are  interesting,  but  which  are  not  fully  un- 
derstood. When  the  function  of  a  portion  of  lung  ceases,  as  it  does 
when  the  air  is  excluded  from  it,  the  cells  and  nuclei  which  it  con- 
tains, and  probably  other  parts,  begin  to  undergo  fatty  degeneration. 
These  elements  become  granular,  somewhat  enlarged  and  opaque, 
and  here  and  there  mixed  with  them  are  other  large  cells  filled 
with  oil  globules.  These  are  the  compound  granular  cells  of  patho- 
logists, and,  occurring  in  this  situation,  are  produced  by  metamor- 


480  BRONCHITIS. 

pilosis  of  the  epitlielicil  cells.  They  are  epithelial  cells  which  have 
progressed  more  rapidly  than  others  in  fatty  degeneration,  having 
reached  that  stage  of  it  which  immediately  precedes  liquefac- 
tion. "\Ye  often  with  the  microscope  observe  not  only  these  cor- 
puscles, but  their  fragments  as  they  are  dissolving.  These  changes 
are  common  in  lobules  which  are  for  a  certain  time  collapsed  and 
congested,  whether  or  not  pneumonia  has  supervened. 

If  the  lobules  remain  collapsed  for  a  considerable  period  on 
account  of  the  feeble  inspiratory  efforts  of  the  child,  and  the  pre- 
sence of  mucus  and  pus  which  obstruct  the  tubes,  they  may  undergo 
such  change  that  they  are  not  inflated,  even  when  the  tubes  be- 
come freed  from  obstruction.  If  an  opportunity  is  presented  of 
examining  the  lungs  at  this  time,  it  will  be  found  difficult,  if  not 
impossible,  to  expand,  even  by  strong  insufflation,  the  lobules 
which  have  been  for  a  considerable  period  collapsed  and  more  or 
less  congested.  These  lobules  have  a  greater  specific  gravity  than 
water,  and  closely  resemble  lobules  which  are  solidified  by  inflam- 
mation; but  when  the  changes  occur  which  have  been  detailed 
above,  there  is  obviously  no  true  pneumonia  at  first. 

Pneumonia  is,  however,  a  not  infrequent  complication  and  result 
of  capillary  bronchitis.  While  in  certain  lobules  collapse  and 
simple  congestion  occur,  others  may  be  afffected  by  a  true  inflam- 
mation extending  from  the  adjacent  inflamed  tubules.  Therefore 
in  fatal  cases  it  is  not  unusual  to  find  in  the  same  lung  lobules 
collapsed  and  congested,  and  others  hepatized.  In  the  former 
there  is  diminution  in  the  size  of  the  alveoli,  with  sim]3le  conges- 
tion, while  in  the  latter  the  alveoli  are  of  full  size,  or  distended  in 
consequence  of  the  abundant  proliferation  of  cells  within  them. 
Pneumonia  may  also  occur  as  a  sequel  of  capillary  bronchitis  in 
lobules,  which  in -consequence  of  the  feebleness  of  the  infant,  or 
other  cause,  remain  collapsed  and  congested,  since  tissues  remain- 
ing in  a  state  of  passive  congestion  are  very  prone  to  inflammation. 
That  pneumonia,  subacute  and  catarrhal,  does  occur  in  the  collapsed 
lobules,  is  demonstrated  by  the  fact  of  a  proliferation  of  cells  with- 
in the  alveoli. 

Minute  abscesses,  usually  directly  under  the  pleura,  have  occa- 
sionally been  observed  at  the  autopsies  of  those  who  have  recently 
had  capillary  bronchitis,  and  pathologists  are  not  agreed  as  to  the 
mode  in  which  they  are  produced.  Some  of  them,  if  not  all,  are 
evidently  connected  with  the  minute  bronchial  tubes,  and  the 
quantity  of  pus  contained  in  each  is  not  usually  more  than  one  or 


\ 


SYMPTOMS.  481 

two  drops.  The  most  reasonable  view  of  their  causation  is  that 
they  are  produced  in  the  terminal  tubes  where  the  mucus  and  pus 
collect.  The  pus  acts  as  an  irritant  and  causes  inflammation,  and 
the  inflammation  increases  the  quantity  of  pus.  The  walls  of  the 
tube  which  is  now  the  seat  of  an  abscess  are  destroyed  by  ulcera- 
tion, and  probably,  also,  some  of  the  contiguous  air  cells.  The 
little  cavity  is  soon  surrounded  by  a  delicate  membrane,  the  same 
in  character,  though  less  thick  and  firm,  with  that  which  consti- 
tutes the  walls  of  larger  abscesses.  The  pus  presents  the  usual 
appearance  of  this  liquid,  or  it  may  be  tinged  by  the  presence  of 
blood  cells,  or  again  it  may  be  thick  from  partial  absorption  of  the 
liquor  puris  so  as  to  resemble  softened  tubercle. 

The  abscess  is  ordinarily  located  in  the  centre  of  a  collapsed 
lobule.  In  certain  cases  it  approaches  the  surface  of  the  lungs,  so 
as  to  produce  circumscribed  pleurisy,  with  adhesion,  of  the  costal 
and  visceral  pleura.  At  the  autopsy  of  such  a  case,  on  separating 
the  adhesions  and  attempting  insufliation,  the  air  passes  through 
the  aperture,  so  that  the  lung  on  that  side  cannot  be  inflated  unless 
the  aperture  is  closed.  Occasionally  pneumothorax  results  from 
opening  of  the  abscess  into  the  pleural  cavity. 

Dilatation  of  the  bronchial  tubes  is  an  occasional  result  of  bron- 
chitis, especially  when  severe  and  protracted.  Emphysema  is  a 
common  lesion  observed  in  young  children,  whether  death  has 
occurred  from  disease  of  the  respiratory  or  some  other  system.  It 
is  observed  most  frequently  in  the  upper  lobes,  and  oftener  in  their 
anterior  than  posterior  portions.  If  it  is  vesicular,  the  sacs  of  air 
are  numerous  and  minute,  but  if  interstitial,  they  are  large  and 
irregular.  If  they  are  upon  or  near  the  surface  of  the  lung  so  as  to 
distend  the  pleura,  they  may  attain  considerable  size.  I  have  seen 
them  of  the  size  of  a  filbert  in  infants  under  the '  age  of  one  year. 
In  exceptional  cases  there  are  many  of  these  air  bladders  situated 
between  the  root  of  the  lung  and  its  anterior  border,  and  percep- 
tibly augmenting  its  volume.  Severe  bronchitis  attended  by  labored 
respiration  and  a  large  collection  of  muco-pus  in  the  tubes,  while 
it  produces  collapse  of  certain  lobules,  is  recognized  as  a  common 
cause  of  these  emphysematous  lesions. 

Symptoms. — It  is  evident,  from  the  description  which  has  been 
given  of  the  anatomical  characters  of  bronchitis,  that  its  symptoms 
vary  greatly  in  severity  in  difterent  patients.  It  usually  com- 
mences with  more  or  less  coryza.  The  symptoms  are  headache, 
flushed  face,  elevation  of  temperature,  acceleration  and  fulness  of 
pulse.  In  the  mildest  cases  these  symptoms  are  scarcely  appreciable. 
31 


482  BEONCHITIS. 

The  child  is  observed  to  sneeze  and  have  some  defluxion  from  the 
nostrils,  and  this  is  followed  by  an  occasional  mild,  almost  painless, 
cough,  which  declines  in  the  course  of  a  few  days.  The  respira- 
tion and  pulse  are  scarcely  accelerated,  and  the  appetite  is  but 
slightly  impaired.  There  may  be  a  little  fretfulness,  but  the 
child  is  not  confined  to  his  bed  or  room,  and  usually  amuses  him- 
self with  his  playthings.  Auscultation  in  these  mild  cases  reveals 
coarse  mucous  rales  in  the  larger  bronchial  tubes,  while  the  smaller 
tubes  are  free  from  mucus.  Sibilant  and  sonorous  rales  are  also 
observed,  especially  in  the  commencement  of  the  bronchitis,  at 
which  time  the  secretion  of  mucus  is  suppressed  or  scanty.  The 
cough  in  the  commencement  is  for  the  same  reason  dry.  It  be- 
comes looser  by  the  second  or  third  day,  the  sputum  consisting  of 
frothy  mucus,  with  the  admixture  of  pus  and  epithelial  cells.  The 
pus  becomes  more  abundant  as  the  disease  continues.  Expectora- 
tion does  not  usually  occur  till  after  the  age  of  four  or  five  years ; 
under  this  age  the  sputum  is  ordinarily  swallowed. 

The  mild  form  of  bronchitis  described  above,  that  in  which 
only  the  larger  bronchial  tubes  are  affected,  is  common  at  all 
periods  of  infancy  and  childhood,  but  a  severer  grade  of  the  dis- 
ease is  also  of  common  occurrence,  exclusive  of  those  cases  in 
which  the  minute  branches  of  the  bronchial-tree  are  affected.  It 
has  already  been  stated  that  there  is  a  tendency  in  bronchial  in- 
flammation to  extend  downwards,  and  symptoms  are  proportionate 
in  gravity  to  the  degree  of  this  extension.  In  severe  bronchitis 
the  pulse  rises  to  120  or  130  per  minute,  and  the  respiration  is  in 
a  corresponding  degree  accelerated.  The  cough  is  frequent  and 
painful,  the  pain  being  referred  to  the  sternum,  and  often  there  is 
a  steady  dull  pain  in  this  region.  The  face  is  flushed  and  indica- 
tive of  suffering,  the  temperature  is  considerably  elevated,  and 
the  appetite  is  greatly  impaired  or  lost.  There  is  frequently  an 
exacerbation  of  symptoms  in  the  latter  part  of  the  da}^  Depres- 
sion of  the  infra-mammary  region  during  inspiration,  and  dilatation 
of  the  alse  nasi,  accompany  grave  attacks  of  the  inflammation. 

Auscultation  in  severe  bronchitis  reveals  the  presence  of  rales 
in  all  parts  of  the  chest,  sibilant  and  sonorous  sparingly,  coarse 
mucous  and  sub-crepitant  more  abundantly. 

Capillary  bronchitis  or  suffocative  catarrh,  the  most  dangerous 
form  of  this  inflammation,  is  less  frequent  than  bronchitis,  which 
is  limited  to  the  larger  tubes,  or  to  the  larger  tubes  and  those  of 
medium  size.  It  may  commence  quite  abruptly,  but  ordinarily 
it  results  from  the  milder  form  of  the  disease.     The  symptoms  at 


SYMPTOMS.  483 

first,  are  such  as  occur  in  the  common  form  of  bronchial  inflamma- 
tion, but  instead  of  abating  or  remaining  stationary,  they  gradu- 
ally increase  in  severity  till,  suddenly,  marked  dyspnoea  super- 
venes. The  inflammation  has  now  reached  the  minute  tubes,  and 
what  promised  to  be  an  ordinary  attack  of  bronchitis  becomes  one 
of  great  severity  and  danger. 

The  respiration  in  capillary  bronchitis  is  short  and  hurried. 
Sixty  to  eighty  inspirations  per  minute  are  not  infrequent,  while 
the  pulse  also  is  greatly  accelerated,  attaining  as  high  a  number  as 
140  to  160  or  180  beats  per  minute.  The  cough  is  fre(][uent,  and 
the  sputum,  which  collects  in  abundance,  is  expectorated  with 
difiiculty.  If  expectorated  so  as  to  be  examined,  it  is  found  to 
consist  largely  of  frothy  mueus  with  epithelial  cells.  After  a  few 
days,  if  the  patient  live,  it  becomes  more  purulent.  Sometimes, 
as  in  bronchitis  of  the  adult,  streaks  of  blood  appear  upon  the 
mucus.  In  the  first  days  of  capillary  bronchitis,  the  temperature 
is  considerably  elevated,  the  face  flushed  and  indicative  of  sufter- 
ing.  The  patient  is  restless,  moving  from  one  part  of  the  bed  to 
another,  seeking  in  vain  for  relief.  The  digestive  function  is 
impaired,  as  in  all  severe  inflammations ;  the  tongue  is  moist  and 
covered  with  a  light  fur;  the  appetite  is  nearly  or  quite  lost.  The 
nursing  infant  nurses  with  difiiculty,  frequently  relinquishing  the 
breast  on  account  of  the  dyspnoea ;  older  children  take  no  solid 
food  in  consequence  of  the  anorexia  and  the  dyspnoea,  and  even 
drinks  are  swallowed  hastily  and  apparently  without  relish,  since 
deglutition  interferes  with  respiration.  On  auscultation  in  capillary 
bronchitis,  at  first  sibilant,  and  after  a  day  or  two  sub-crepitant, 
rales  are  observed  in  every  part  of  the  chest.  Percussion  elicits  a 
good  resonance,  unless  the  substance  of  the  lung  has  become 
involved.  As  the  disease  approaches  a  fatal  termination,  the  pulse 
becomes  greatly  accelerated,  the  respiration  is  also  in  a  corres- 
ponding degree  frequent  and  panting,  the  inspiration  being  accom- 
panied by  marked  infra-mammary  depression  and  dilatation  of  the 
alse  nasi.  The  face  becomes  pallid,  the  prolabia  livid,  and  the  tips 
of  the  fingers  livid  and  cool.  The  mucus  and  pus,  accumulating  in 
the  air  passages,  increase  more  and  more  the  obstruction  to  the  en- 
trance of  air,  and,  finally,  death  occurs  from  ajDuoea.  The  nursing 
infant  usually  ceases  to  nurse  for  several  hours  before  death,  and  a 
state  of  stupor  commonly  precedes  the  fatal  event,  in  consequence 
of  the  carbonaceous  state  of  the  blood.  In  young  infants,  espe- 
cially those  under  the  age  of  six  months,  not  only  in  capillary 
bronchitis,  but  in  severe  ordinary  bronchitis,  I  have  often  observed 


484  BRONCHITIS. 

toward  the  close  of  life,  intermissions  in  the  respiration.  It  occurs 
after  every  six  or  eight  or  ten  respirations,  and  equals  in  duration 
the  time  occupied  in,  jDcrhaps,  half  a  dozen  respiratory  movements. 
It  is,  therefore,  an  unfavorable  prognostic,  but  some  recover  by 
stimulation  in  whom  it  occurs. 

The  duration  of  acute  bronchitis  varies  accordino-  to  the  extent 
of  the  inflammation.  In  the  mildest  form,  the  patient  is  con- 
valescent after  three  or  four  days,  and,  in  severer  forms  that 
terminate  favorably,  the  disease  begins,  ordinarily,  to  decline  by 
the  close  of  the  first  week  or  in  the  second.  The  progress  of 
bronchitis  is  somewhat  more  rapid  in  young  children  than  in  those 
of  a  more  advanced  age.  When  convalescence  is  fully  established, 
it  is  not  unusual  for  the  cough  to  continue  three  or  four  weeks, 
though  gradually  declining.  It  is  loose  and  painless,  and  is 
scarcely  regarded  by  the  patient. 

Death  sometimes  occurs  as  early  as  the  second  or  third  day  in 
capillary  bronchitis.  The  younger  the  infant,  with  the  same 
extent  and  intensity  of  inflammation,  of  course  the  sooner  the  fatal 
result.  The  ordinary  duration  of  fatal  bronchitis  is  from  six  to 
eight  days.  If  the  patient  pass  beyond  the  tenth  day,  decline  of 
the  inflammation  may  be  confidently  expected,  and  recovery,  unless 
there  is  a  complication. 

Occasionally  bronchitis  becomes  chronic,  lasting  several  months 
before  it  entirely  ceases.  The  chronic  form  may  result  from  mild, 
as  well  as  severe,  bronchitis.  The  active  fever  and  accelerated 
respiration  which  characterize  the  acute  affection  abate,  and  the 
general  health  is  nearly  or  quite  restored ;  but  an  occasional  cough 
continues,  and  the  respiration  is  often  audible,  from  the  mucus 
which  collects  in  the  tubes,  or  from  thickening  of  the  mucous 
membrane.  Sometimes  there  is  moderate  febrile  movement,  espe- 
cially in  the  latter  part  of  the  day.  On  auscultation,  coarse 
mucous,  with  perhaps  sibilant  and  sonorous,  rales  are  observed  in 
the  chest. 

There  is  great  liability  in  chronic  bronchitis  to  exacerbations. 
The  disease  often  seems  to  be  abating,  and  there  is  prospect  of  its 
speedy  cure,  when  all  the  symptoms  are  intensified.  The  exacerba- 
tions are  due  to  the  fact  that  the  bronchial  surface,  when  it  has 
been  a  considerable  time  inflamed,  is  very  sensitive  to  the  im- 
pression of  cold.  Even  when  the  disease  is  entirely  relieved,  it 
is  very  apt  to  return  by  exposure  to  currents  of  air  or  changes  of 
temperature.  Chronic  bronchitis  occurs  most  frequently  in  the 
winter  and  in  the  spring  and  fall,  when  the  Aveather  is  changeable, 


DIAGNOSIS  —  PROGNOSIS,  485 

and  is  most  intractable  in  these  periods  of  the  year.  Many  cases  of 
chronic  bronchitis  are  associated  with  dilatatipn  of  the  bronchial 
tubes  or  with  emphysema.  The  general  health  in  chronic  bron- 
chitis, when  not  dependent  on  a  tubercular  deposit,  ordinarily 
remains  good.  Tubercular  bronchitis,  which  is  the  result  of  a 
grave  disease,  does  not  require  a  separate  consideration.  It  is 
attended  with  emaciation,  and  is  obstinate  on  account  of  the 
nature  of  the  primary  aficction.  It  is  due  to  the  irritating  effect 
of  tubercular  matter  lying  against  the  bronchial  tubes. 

Diagnosis. — Bronchitis  can  ordinarily  be  diagnosticated  by  the 
character  of  the  respiration  and  cough.  The  absence  of  hoarseness, 
stridulous  inspiration,  and  croupy  cough,  excludes  laryngitis ;  and 
the  absence  of  the  expiratory  moan  and  of  the  stitch -like  pain  on 
coughing,  which  characterize  pneumonia  and  pleurisy,  excludes 
those  diseases.  Accurate  diagnosis,  however,  can  be  most  readily 
made  by  percussion  and  auscultation.  Examination  of  the  chest 
enables  us  to  state  with  positiveness,  not  only  the  nature,  but  the 
extent  of  the  atfection.  If  the  inflammation  is  confined  to  the 
larger  bronchial  tubes,  coarse  rales  are  discovered  in  them,  while 
finer  mucous  rales  are  absent.  If  the  bronchitis  is  capillary,  sub- 
crepitant  rales  are  discovered  in  the  smaller  tubes.  Percussion  gives 
clear  resonance  on  both  sides,  except  in  those  instances  in  which 
collapse  or  pneumonia  has  supervened. 

Prognosis. — Bronchitis,  limited  to  the  larger  bronchial  tubes, 
or  to  these  and  those  of  medium  size,  terminates  favorably  in  a 
large  majority  of  cases.  Occasionally,  severe  inflammation,  not 
extending  to  the  smaller  tubes,  proves  fatal  in  young  infants,  or 
those  of  feeble  constitution.  True  capillary  bronchitis  is,  on  the 
other  hand,  a  disease  of  great  danger.  It  may  be  fatal  at  any 
period  of  childhood,  but  the  younger  the  patients  and  more  feeble, 
the  greater  the  proportion  of  deaths.  Under  the  age  of  one  year, 
it  is  one  of  the  most  fatal  diseases  of  early  life. 

The  prognosis,  in  the  commencement  of  all  cases  of  bronchitis 
of  average  severity  in  the  young  child,  should  be  guarded,  on 
account  of  the  tendency  of  the  inflammation  to  extend,  since 
ordinary  bronchitis  may  become  capillary.  After  five  or  six  days, 
extension  ceases,  and,  if  during  that  time  there  is  no  increase  in 
the  severity  of  symptoms,  the  prognosis  is  favorable.  Signs  which 
indicate  an  unfavorable  result  are  increasing  frequency  of  pulse 
and  respiration,  difiicult  and  scanty  expectoration,  restlessness,  -a 
countenance  indicative  of  suftering,  and  a  progressively  greater 
accumulation  of  mucus  in  the  bronchial  tubes,  as  determined  by 


486  BEONCHITIS. 

auscultation.  Pallor  and  coldness  of  tlie  face  and  extremities, 
lividity  of  the  tips  of  the  fingers,  rapid  and  feeble  pulse,  drowsi- 
ness, diminution  of  cough,  while  the  mucus  and  pus  accumulate  in 
the  bronchial  tubes,  and,  in  young  children,  intermissions  in  the 
respiration,  indicate  the  near  approach  of  death.  Cases  may,  how- 
ever, recover  by  proper  treatment,  although  the  symptoms  are 
most  unfavorable. 

It  is  unnecessary  to  mention  the  favorable  prognostic  signs  of 
bronchitis.  This  disease,  when  fully  established,  continues  a  cer- 
tain number  of  days,  whatever  remedial  measures  are  employed, 
and  if  the  symptoms  do  not  increase  in  severity  during  the  first  five 
or  six  days,  a  favorable  result  is  highly  probable.  The  prognosis 
in  chronic  bronchitis  is  ordinarily  favorable,  so  far  as  life  is  con- 
cerned, provided  there  is  no  emaciation.  If  there  is  emaciation, 
the  bronchial  inflammation  may  be  due  to  tubercles  in  the  bronchial 
glands  or  lungs,  and,  of  course,  the  prognosis  is  unfavorable. 

Treatment. — Bronchitis  may  be  rendered  much  milder,  and 
perhaps  even  prevented,  by  an  emetic  employed  in  the  first  twelve 
or  twenty-four  hours,  in  conjunction  with  a  warm  bath.  The 
physician  is  not,  however,  ordinarily  called  sufliciently  early  to 
render  this  treatment  efiectual.  The  remedial  measures  proper  for 
this  disease  vary  greatly,  according  to  the  stage  and  intensity  or 
extent  of  the  inflammation  and  the  age  of  the  patient.  Bronchitis, 
limited  to  the  larger  tubes,  requires  simple  measures.  A  laxative 
may  be  employed,  with  a  mild  expectorant,  and  moderate  counter- 
irritation  should  be  produced  by  camphorated  oil,  or  the  occasional 
employment  of  a  sinapism.  I  have  sometimes  ordered  for  these 
cases  a  mixture  recommended  by  Dr.  James  Jackson,  of  Boston, 
in  his  letters  to  a  young  physician.  "  For  young  children,"  .... 
says  he,  "  I  employ  the  following :  Take  of  either  almond  or  olive 
oil,  of  syrup  of  squills,  of  any  agreeable  syrup,  and  of  mucilage  of 
gum  acacia,  equal  parts,  and  mix  them.  Of  this  mixture,  a  tea- 
spoonful  may  be  given  to  a  child  at  two  years  of  age ;  a  little  less 
if  younger,  and  increased  if  older,  so  as  to  double  the  dose  to  one 
in  the  sixth  year.  This  may  be  given  from  three  to  six  times  in 
the  twenty-four  hours.  Sometimes  a  little  opiate  must  be  added 
at  night  to  appease  an  urgent  cough."  These  cases  also  do  well 
with  simple  mucilaginous  drinks  in  conjunction  with  gentle  ape- 
rients. 

Bronchitis,  extending  beyond  the  primary  or  secondary  bronchial 
divisions,  requires  more  careful  watching  and  more  decided  mea- 
sures.    The  abstraction  of  blood  by  leeches,  or  otherwise,  is  seldom 


TREATMENT.  487 

required  in  the  treatment  of  bronchitis.  Occasionally,  it  the  in- 
flammation is  intense  and  the  symptoms  urgent,  moderate  abstrac- 
tion of  blood  at  an  early  period  may  be  useful,  but  the  employment 
of  cardiac  sedatives  under  such  circumstances  is  generally  prefer- 
able. 

As  a  rule,  actively  depressing  agents  should  be  avoided  in  the 
treatment  of  bronchitis  in  patients  under  the  age  of  two  years ; 
and,  on  the  other  hand,  sustaining  remedies  are  in  a  large  propor- 
tion of  cases  required  after  the  first  two  or  three  days.  Many 
infants  with  bronchitis  are  sacrificed  in  consequence  of  the  old 
theory,  which  still  influences  medical  practice,  that,  an  inflamma- 
tion, with  its  increased  force  of  circulation,  is  necessarily  Ijest 
controlled  by  depletory  and  sedative  measures.  Remedies  too  de- 
pressing are  prescribed,  and  with  a  less  favorable  result  than 
would  follow  a  strictly  expectant  course  of  treatment. 

What  is,  therefore,  the  proper  mode  of  treating  bronchitis, 
severe  or  of  ordinary  gravity,  occurring  in  infancy  and  childhood  ? 
It  is  supposed  that  the  physician  is  called  when  the  inflammation 
is  fully  established,  or  that,  if  he  has  seen  the  patient  at  the  com- 
mencement, and  has  prescribed  an  emetic,  it  has  failed  to  throw 
off  the  disease.  A  large  emollient  poultice,  not  thicker  than  the 
cover  of  a  book,  so  wet  as  to  produce  constant  moisture  of  the 
surface,  and  sufliciently  irritating  to  produce  constant  redness 
without  necessitating  its  removal,  should  be  applied  to  the  front 
and  sides  of  the  chest,  and  over  it  an  oil-silk  jacket  placed.  I  pre- 
fer a  poultice  of  the  following: — 

R.  Pnlv.  sinapis  §ss  ; 

Pulv.  sernin.  lini  §viij.     Misce. 

Local  treatment  in  bronchitis  is  very  important.  The  exact 
mode  of  applying  it,  or  the  substances  used,  matters  little,  provided 
it  meets  the  indication,  which  is  twofold — namely,  derivation  to 
the  surface,  and  the  application  to  it  of  warmth  and  moisture. 
Such  applications  are  found,  by  experience,  to  give  most  relief. 
Warmth  and  moisture  are  furnished  by  cataplasms  most  con- 
veniently, or  by  warm  water  applications  under  oil-silk. 

Derivation  to  the  surface,  early  made  and  repeated,  tends  to 
check  the  downward  extension  of  bronchitis  ;  but  it  is  not  advisable 
to  vesicate,  or  to  produce  anything  more  than  moderate  and  con- 
tinued redness.  Often  improvement  in  symptoms  is  observed, 
especially  less  dyspnoea  and  restlessness,  immediately  on  the  em- 
ployment of  the  local  measures  recommended  above. 


488  BRONCHITIS. 

The  general  or  internal  treatment  appropriate  for  bronchitis 
varies  according  to  the  age  and  the  character  of  the  inflammation, 
whether  primary  or  secondarj^  The  following  formula  will  be 
found  useful  for  infants  affected  with  primary  bronchitis: — 

H.  Spts.  aether  nitr.  3j  ; 
Syr.  ipecacuanhag, 
01.  ricini,  aa  3ij  ; 
Syr.  bal.  tolut.  3vij.     Misce. 
One  teaspoonful  for  an  infant  one  year  old  every  two  to  four  hours. 

Another  eligible  formula  is  the  following : — 

R.  Syr.  ipecacuanhas  gij  ; 
Potas.  acetat.  gr.  xvj-^ss  ; 
Aq.  anisi  3xiv.     Misoe. 
Dose,  one  teaspoonful  for  an  infant  of  six  months. 

If  there  is  decided  febrile  reaction,  tincture  of  digitalis,  one  or 
two  drops,  according  to  the  age,  may  be  added  to  each  teaspoonful. 

In  a  majority  of  cases  of  infantile  bronchitis,  this  mode  of  treat- 
ment is  appropriate  only  for  the  first  few  days,  after  which,  if 
farther  medication  is  required,  more  sustaining,  or  even  stimulating, 
medicines  are  proper. 

For  children  over  the  age  of  three  years,  if  the  previous  health 
has  been  good,  and  the  bronchitis  is  primary,  aconite  or  veratrum 
viride  is  often  useful  in  the  first  stage  of  the  inflammation.  The 
following  is  a  recipe  for  a  child  of  five  years : — 

R.  Tinct.  rad.  aconit.  gtt.  xij  ; 
Syr.  scillae  comp.  3ij  ; 
Syr.  bal.  tolut.  gxiv.     Misce. 
One  teaspoonful  every  two  to  four  hours ;  the  medicine  to  be  omitted,  or  given 
at  a  longer  interval,  if  the  frequency  of  the  pulse  is  reduced. 

The  tincture  of  veratrum  viride  is  more  powerful  than  that 
of  aconite,  and  may  be  employed  in  the  same  dose  for  those  who 
are  more  robust. 

The  effect  of  cardiac  sedatives  should  be  carefully  watched.  In 
general  they  should  be  administered  only  during  the  first  three  to 
five  days ;  but  if  the  child  is  robust,  with  full  and  strong  pulse, 
they  may  be  continued  longer.  As  the  active  inflammation  begins 
to  abate,  simple  expectorant  mixtures  may  be  given,  as  syrup  of 
squills,  or  ipecacuanha  in  spiritus  Mindereri!  At  this  stage  of 
bronchitis,  it  is  often  best  to  commence  the  use  of  stimulating  ex- 
pectorants, and  they  are  required  in  nearly  all  cases  of  advanced 
bronchitis.  In  secondary  forms  of  the  disease,  as  when  it  occurs 
in  connection  with  hooping-cough  or  measles,  such  expectorants 


TREATMENT.  489 

should  be  employed  from  the  first;  and  also  if  there  is  a  state  of 
feebleness  or  cachexia,  although  the  bronchitis  is  primary.  It  is 
important  for  successful  practice  to  be  able  to  determine  at  what 
period  in  the  disease  this  class  of  medicinal  agents  should  be  pre- 
scribed. In  doubtful  cases,  it  is  safer  to  prescribe  them  than  those 
of  a  depressing  character;  but  it  is  better  to  employ,  for  a  day  or 
two,  a  simple  mucilaginous  or  other  soothing  mixture,  after  which 
a  stimulating  expectorant  can  be  given.  A  favorite  prescription 
with  me  is  the  following : — 

R.  Ammon.  carbonat.  gr.  xvj-xxiv  ; 
Tinct.  sanguinar.  gtt.  xxiv  ; 
Syr.  senega;  ^ij  ; 
Ext.  glycyr.  3ss  ; 
Aquae  3xiv.     Misce. 
Dose,  ote  teaspoonful  every  two  or  three  hours  to  a  child  of  two  years. 

If  there  is  restlessness,  Dover's  powder,  paregoric,  or  syrup  ot 
poppies  should  be  given  with  this  mixture,  or  separately. 

As  convalescence  approaches,  the  medicine  should  be  administered 
less  and  less  frequently  or  in  smaller  doses.  Emetics  in  ordinary 
cases  of  bronchitis  are  not  required,  except  in  the  commencement. 
In  severe  bronchitis,  however,  especially  when  the  smaller  tubes 
are  inflamed,  they  are  sometimes  of  great  service.  The  cases  which 
require  their  administration  are  those  in  which  mucus  and  pus 
collect  in  the  tubes  more  rapidly  than  they  are  expectorated,  so  as 
to  give  rise  to  urgent  dyspnoea.  ITothing  gives  such  decided  and 
immediate  relief  under  these  circumstances  as  an  emetic.  The 
object  to  be  gained  is  obviously  very  different  from  that  in  the 
commencement  of  bronchitis,  and  such  agents  should  be  employed 
as  act  promptly,  with  the  least  possible  depression.  Sulphate  of 
zinc  or  of  copper  is,  therefore,  an  appropriate  medicine.  The  former 
may  be  given  in  a  dose  of  live  grains ;  the  latter,  of  one  or  two 
grains  to  a  child  five  years  old.  If  there  is  considerable  strength 
of  pulse  and  heat  and  dryness  of  surface,  ipecacuanha  may  be 
administered.  If  there  are  evidences  of  exhaustion,  stimulants 
may  be  administered  immediately  before  and  after  emesis.  Infants 
oppressed  by  the  accumulation  of  mucus  and  pus  may  sometimes 
be  relieved  by  tickling  the  fauces  with  the  finger.  This  provokes 
vomiting,  and  the  viscid  mucus  which  collects  at  the  entrance  of 
the  glottis  is  removed  by  the  finger. 

In  secondary  bronchitis  whatever  the  age,  in  primary  or  second- 
ary occurring  in  infants  or  feeble  children,  the  diet  should,  as  a 
rule,  be  nutritious  through  the  entire  disease.     Robust  patients, 


490  PNEUMONITIS. 

or  those  who  have  had  ordinary  health,  if  over  the  age  of  two 
years  and  aftected  with  primary  bronchitis,  should  have  light  diet, 
chiefly  farinaceous  in  the  first  days  of  the  attack,  after  which 
animal  broths  are  proper.  Whatever  food  is  given  in  severe  bron- 
chitis must  be  in  the  form  of  drinks,  since  the  appetite  is  lost, 
while  the  thirst  is  such  that  liquids  are  less  likely  to  be  refused. 

In  primary  bronchitis,  if  mild  or  of  ordinary  severity,  alcoholic 
stimulants  are  not  required.  In  secondary  bronchitis  they  are 
often  needed,  and  also  in  capillary  or  severe  ordinary  bronchitis 
if  there  is  dyspncea  with  evidences  of  prostration.  The  occasional 
loose  cough  which  is  often  present  during  the  period  of  conva- 
lescence requires  but  little  treatment;  either  no  medicine  or  a 
gently  stimulating  expectorant  may  be  given. 


CHAPTER  y. 

PNEUMONITIS. 


In  children  over  the  age  of  five  or  six  years,  pneumonitis  differs 
but  little  in  form  or  phenomena  from  that  of  the  adult,  being 
ordinarily  primary  except  as  it  depends  on  an  irritant,  as  tubercles, 
and  extending  rapidly  over  one  or  more  entire  lobes.  In  those 
under  the  age  of  five  years  it  is,  on  the  other  hand,  as  a  rule,  a 
secondary  affection,  and  limited  to  a  part  of  a  lobe.  Most  writers, 
until  recently,  have  classified  cases  according  to  their  origin  as 
primary  and  secondary,  or  their  extent  as  lobar  and  lobular,  or 
their  duration  as  acute  or  chronic.  A  better  classification,  having 
an  anatomical  basis,  is  that  into  catarrhal,  croupous,  and  inter- 
stitial. 

Catarrhal  pneumonitis  consists  in  an  inflammation  of  the  air- 
cells,  with  an  abundant  proliferation  of  epithelial  cells  within  them, 
and  the  exudation  of  serum  but  not  of  fibrin.  The  secondary  and 
lobular  pneumonitis  of  young  children,  alluded  to  above,  is  usually 
of  this  character.  Croupous  pneumonitis  consists  also  in  an  inflam- 
mation of  the  alveoli,  but  with  an  abundant  formation  of  pus-cells 
within  them,  and  the  exudation  of  fibrin  and  serum.  The  lobar 
and  primar}^  pneumonitis  of  advanced  children  and  adults  is  com- 
monly of  this  character.  In  both  catarrhal  and  croupous  pneumo- 
nitis, therefore,  the  solidification  of  the  lung  and  exclusion  of  air  are 


CAUSES.  491 

due  mainly  to  the  newlj^-formed  cellular  elements  with  which  the 
alveoli  arc  filled,  though  the  source  and  nature  of  these  cells  differ 
in  the  two  diseases.  Interstitial  pneumonitis  consists  in  an  in- 
flammation and  hyperplasia  of  the  connective  tissue  of  the  lungs. 
It  is  the  chronic  pneumonia  of  authors,  resembling  in  many  respects, 
in  its  anatomical  and  clinical  characters,  cirrhosis  of  the  liver. 
The  inflammation  which  produces  this  result  is  subacute,  and  in 
nearly  all  cases  is  dependent  on  some  persistent  local  disease  in  the 
minute  bronchial  tubes  or  lungs,  as  softened  or  cheesy  tubercles, 
cancer,  abscesses,  protracted  inflammation  of  the  alveoli  or  bron- 
chioles, whether  produced  by  the  inhalation  of  dust  of  an  irritating 
nature  or  other  cause.  Interstitial  pneumonia  is  much  more  rare 
in  children  than  adults,  and,  as  it  presents  no  peculiar  features  in 
them,  it  need  only  be  alluded  to  in  this  connection. 

Causes. — Croupous  pneumonitis  in  most  cases  results  from  that 
common  cause  of  inflammations — namely,  taking  cold.  It  com- 
mences as  a  primary  disease  within  a  few  hours  after  exposure. 
Catarrhal  pneumonitis,  in  exceptional  instances,  also  commences 
abruptly  as  a  primary  disease  from  the  same  cause,  but  being, 
probably  in  nine  cases  out  of  ten,  secondary,  it  commonly  results 
from  antecedent  pathological  states,  which  we  will  enumerate. 

First.  Many  cases  result  from  bronchitis.  The  inflammation 
extending  downward  engages  the  minute  bronchial  tubes,  and 
from  them  traverses  the  alveoli  of  one  or  more  lobules.  This  is 
the  broncho-pneumonia  of  children  described  by  authors ;  it  occurs 
most  frequently  between  the  ages  of  six  and  eighteen  months. 
^.--Secondly.  Hypostasis,  or  passive  congestion,  is  an  important 
factor  in  the  causation  of  many  cases,  and  in  feeble  infants  it  is 
not  infrequently  the  sole  cause.  Infants  with  feeble  health  and 
languid  circulation,  lying  in  their  cribs  day  after  day  with  little 
movement  of  the  body,  are  very  liable  to  passive  congestion  of  the 
depending  portions  of  their  lungs,  and  this  by  and  by  eventuates 
in  a  cell  proliferation  within  the  alveoli — in  other  words,  a  pneumo- 
nia presenting  some  peculiarities,  but  of  the  catarrhal  form.  In 
foundling  hospitals,  where  feeble  infants  are  received  and  treated, 
this  is  one  of  the  most  frequent  pathological  states,  and  is  the  pre" 
vailing  form  of  j)ulnionary  inflammation-.-  It  is  sometimes  de- 
scribed as  hypostatic  pneumonia.  Hence  physicians,  whose  obser- 
vations have  been  largely  in  such  institutions,  have  almost  ignored 
any  other  form  of  pneumonia  in  infants.  Billard,  a  close  and 
accurate  observer,  wrote  nearly  half  a  century  ago :  "  Pneumonia 
of  infancy  presents  peculiar  characters,  in  which  it  differs  from  the 


492  PNEUMONITIS. 

same  aiFection  in  adults.  Instead  of  being  an  idiopathic  affection 
arising  from  irritation  developed  in  the  pulmonary  tissue  under 
the  influence  of  atmospheric  causes,  which  often  excite  the  disease, 
the  pneumonia  of  young  infants  is  evidently  the  result  of  a  stagna- 
tion of  blood  in  their  lungs.  Under  these  circumstances  this 
blood  may  be  regarded  as  a  kind  of  foreign  body  ....  It  would, 
therefore,  appear  that  inflammation  of  the  lungs,  which  produces 
hepatization,  arises  in  infants,  in  general,  from  some  mechanical  or 
l^hysical  cause."  Valleix  also  states  that  he  found  the  lesions  of 
pneumonia  in  a  majority  of  the  infants  who  died  in  the  Hopital 
des  Enfants  Trouves.  The  statements  of  Valleix  are  applicable  also 
to  the  Infants'  Hospital,  and  ]N'ursery  and  Child's  Hospital,  of  this 
city,  as  regards  those  cases  in  which  death  results  from  chronic 
disease.  We  shall  see  hereafter  that  hypostatic  pneumonia  is  one 
of  the  most  common  complications  of  chronic  infantile  entero- 
colitis, the  summer  complaint  of  the  cities. 

Thirdly.  Catarrhal  pneumonia  of  infants  sometimes  results  from 
collapse.  It  is  not  unusual  to  find,  at  the  autopsies  of  infants  who 
have  died  in  a  state  of  emaciation  and  feebleness,  portions  of  the 
lungs  remote  from  the  bronchi  collapsed,  as,  for  example,  the  thin 
edges  of  the  inferior  lobes,  and  the  tongue-like  process  of  the  left 
upper  lobe,  the  process  which  lies  over  the  heart.  The  immediate 
cause  of  the  collapse  has  been  a  bronchitis,  or  it  has  resulted  di- 
rectly from  the  general  weakness  of  the  infant,  and  its  feeble  res- 
pirations. N'ow,  a  collapsed  lung  soon  becomes  affected  by  passive 
congestion.  The  functional  activity  of  an  organ  favors  circulation 
through  it,  and  if  the  function  is  abolished  the  flow  of  blood  in 
the  part  is  retarded,  and  stasis  more  or  less  complete  results.  The 
hyperffimic  state  of  collapsed  pulmonary  lobules  presents  the  same 
anatomical  condition  for  the  supervention  of  pneumonia,  as  occurs 
in  cases  of  hypostatic  congestion.  Consequently,  cell  proliferation 
soon  begins  in  the  collapsed  alveoli,  the  volume  of  the  affected 
lung  increases,  and  it  becomes  firmer  and  more  resisting  to  the 
touch,  and  the  microscope  reveals  the  characters  of  a  subacute  but 
genuine  catarrhal  pneumonitis.  I  have  made  or  have  procured 
microscopic  examinations  of  a  considerable  number  of  such  speci- 
mens, and  have  found  the  alveoli  more  or  less  filled  with  cells  of 
the  epithelial  character. 

In  rare  instances  in  infancy  and  childhood  pneumonitis  results, 
as  it  more  frequently  does  in  the  adult,  from  an  embolus  detached 
from  a  clot,  which  had  formed  in  some  remote  vein,  in  consequence 
of  arrest  of  circulation  in  it,  by  inflammation  of  the  contiguous 


ANATOMICAL    CHARACTERS.  493 

tissues.  This  is  described  by  writers  as  a  distinct  form  of  pneumo- 
nitis designated  embolic  or  cmbolismal.  A  specimen  showing  this 
mode  of  causation  was  exhibited  by  me  at  the  New  York  Patho- 
logical Society,  in  February,  1868.  An  infant  born  January  22d, 
1868,  of  strumous  parents,  had  been  fretful,  but  without  appreciable 
ailment  till  February  3d,  when  inflammation  of  the  connective 
tissue  occurred  on  the  anterior  aspect  of  the  left  leg,  a  little  below 
the  knee.  This  extended  downwards,  suppurated,  and  the  pus 
was  evacuated  February  5th.  In  the  mean  time,  three  other  similar 
inflammations  occurred,  two  on  the  right  foot  and  leg,  and  the 
other  over  the  parietes  of  the  chest  in  the  right  infra-mammary 
region.     Suppuration  occurred  in  all  of  these. 

On  February  8th  this  infant  was  suddenly  seized  with  extreme 
dyspnoea,  and  died  in  a  few  hours.     l!^umerous  minute  puriform 
collections  (formerly  called  metastatic  abscesses)  were  discovered 
in  each  lung,  most  of   them  scarcely 
larger  than  a  pin's  head.     One  of  them        p\  ~,      f^,?, 

on  the  right  side  in  the  middle  lobe        '"^M  Vi^if^^l^} 
connecting  with  a  bronchial  tube  had         jWif  %'-MM,'B0 
ruptured  into  the  pleural  cavity,  cans-         w^'^^^i^h^  '^^"'^^^ 
ing  pneumothorax,  collapse,  and  incipi-         |4,  mMM}.       t^v?^-. 

ent  pleuritis.  ^  ^^^''Wjil  -^#^ 

The   annexed    figure    exhibits   the      i^li^  f ^\l5Mil>^>  \1 '':*'1    / 
microscopic  appearance  of  this  softened      "^^^  "fMm^^^m^  ' '^*"*  ^"^^ 
fibrin,   which,   to   the   naked   eye,   so        "    '''''^^^^m^  ^ 
closely  resembled  pus. 

On  account  of  the  speedy  death,  the  emboli  had  produced,  in  the 
lobules  where  they  had  lodged,  little  more  than  congestion  or  the 
first  stage  of  pneumonitis  around  them.  Had  the  infant  lived 
longer,  doubtless  the  ferments  or  the  vibriones,  which  some  con- 
sider the  irritating  element  of  emboli,  would  have  produced  sup- 
purative inflammation. 

Anatomical  Characters. — Nothing  need  be  added  in  this  con- 
nection to  what  has  already  been  said,  in  reference  to  interstitial 
and  embolismal  pneumonias.  Being  comparatively  rare  in  children, 
they  present  the  same  anatomical  characters  as  in  the  adult.  That 
unimportant  form  of  pneumonia  called  pleurogenous,  and  which 
consists  in  a  croupous  inflammation  of  the  superficial  infundibula  of 
the  lung  underneath  an  inflamed  pleura,  occurs  in  children  as  well 
as  adults.  Being  secondary  to  the  pleuritis  produced  by  extension 
of  the  inflammation  of  the  pleura,  it  gives  rise  to  no  physical  signs, 
or  appreciable  symptoms,  on  account  of  its  slight  extent,  and  as  it 
presents  no  peculiar  features  in  the  child,  it  need  only  be  alluded  to. 


494  PNEUMONITIS. 

Croupous  pneumonitis,  •winch  we  have  stated  is  the  ordinary  form 
of  puhiiouarj  inflammation  in  children  over  the  age  of  five  years,  has 
the  same  anatomical  characters  as  in  the  adult.  It  ordinarily  in- 
volves an  entire  lobe.  It  is  more  frequent  in  the  right  than  left 
lung,  and  in  whichever  lung  it  occurs  its  most  frequent  seat  is 
the  lower  lobe.  The  inflammation  may,  however,  be  limited  to  an 
upper  lobe,  especially  on  the  right  side.  It  ordinarily  commences 
near  the  root  of  the  luns;  and  extends  forward. 

Croupous  pneumonitis  presents  three  stages,  that  of  congestion, 
red  hepatization,  and  gray  hepatization.  In  the  stage  of  conges- 
tion the  capillaries  in  the  walls  of  the  alveoli  are  greatl}^  distended, 
bulging  forward  in  loops  within  the  alveolar  spaces  so  as  to  diminish 
them,  and  a  viscid  albuminous  fluid  begins  to  exude,  in  which 
points  of  extra vasated  blood  appear.  The  afifected  lung  in  this 
stage  has  a  deep  red  color,  its  elasticity  is  greatly  diminished,  and 
its  density  and  weight  increased.  On  account  of  the  reduced  size 
of  the  alveoli  from  the  bulging  of  the  alveolar  walls,  and  the 
viscid  fluid  within  the  alveoli  and  terminal  bronchial  tubes,  the 
function  of  the  alFected  lobe  is  nearly  lost,  and  hence  the  dyspnoea 
which  patients  experience  in  the  first  stage  of  the  inflammation. 

The  second  stage  is  characterized  by  the  continued  and  increased 
escape  of  the  liquor  sanguinis,  and  red  and  white  corpuscles, 
through  the  stigmata  or  little  apertures  which  exist  normally  in 
the  walls  of  the  capillaries.  The  inflamed  alveoli,  and  the  minute 
bronchial  tubes  which  terminate  in  them,  are  filled  with  this 
pneumonic  exudation.  The  relative  proportion  of  the  elements 
of  the  blood  in  the  exudate  varies  in  different  cases.  Fibrin 
is  always  present,  immediately  coagulating  in  delicate  filaments 
within  the  interstices  of  which  the  corpuscles  are  lodged.  The 
white  corpuscles  in  some  cases  are  much  in  excess  of  the  red,  while 
in  others  the  red  predominate.  The  lung  in  the  second  stage  con- 
tains no  air,  has  a  greater  specific  gravity  than  water,  is  friable  so 
as  to  be  readily  torn  and  penetrated  by  the  finger.  The  torn 
surface  in  the  adult  presents  a  granular  appearance,  each  granule 
being  the  contents  of  an  air-cell.  In  the  child  the  granules  are 
not  distinct  on  account  of  the  small  size  of  the  air-cells,  but  the 
volume  of  the  inflamed  lobe  is  somewhat  increased  as  in  the  adult. 

The  stage  of  gray  hepatization  succeeds,  in  which  the  volume 
of  the  lung  is  still  greater.  The  change  of  color  is  due  partly  to 
the  compression  of  the  capillaries  by  the  inflammatorj'-  material, 
partly  to  the  destruction  of  the  red  corpuscles,  and  disappearance  to 
a  greater  or  less  extent  of  their  coloring  matter,  while  the  white 


ANATOMICAL    CHARACTERS.  495 

corpuscles  (pus-cells)  rem:un,  but  more  to  commencing  fatty  degene- 
ration in  the  exudate  prior  to  its  liquefaction.  In  favorable  cases 
the  lung  soon  returns  to  its  normal  state,  the  liquefied  substance 
which  tilled  the  alveoli  being  in  part  absorbed,  in  part  expectorated. 

Croupous  pneumonitis  often  causes  inflammation  of  the  portion 
of  the  pleura  which  covers  it.  Pleuritis  developed  in  this  way  is 
circumscribed,  but  it  frequently  extends  beyond  the  inflamed 
parenchyma  to  the  distance  of  one  or  two  inches.  Bronchitis  is 
also  a  common  accompaniment.  It  may  be  general,  in  which  case 
it  occurs  independently,  or  be  limited  to  the  tubes  lying  within 
the  inflamed  lung,  in  which  case  it  results  like  the  pleuritis  from 
the  pneumonitis.  It  is  seen  from  this  description  that  the  pus-cells 
which  are  produced  so  abundantly  in  the  alveoli  are  believed  to  be 
chiefly  exuded  white  corpuscles  of  the  blood.  Possibly  some  of 
them  may  be  produced  by  jjroliferation  of  the  epithelial  cells, 
which  line  the  alveoli,  in  the  same  manner  as  they  are  believed 
to  be  produced  in  the  bronchial  tubes. 

Catarrhal  pneumonitis,  which  is,  as  we  have  stated,  for  the  most 
part  the  lobular  pneumonitis  of  writers,  and  which,  with  an  occa- 
sional exception,  is  the  form  of  inflammation  in  children  under  the 
age  of  five  years,  presents  not  only  clinical  but  anatomical  features, 
which  distinguish  it  from  the  croupous  form  of  the  disease.  Those 
who  have  witnessed  few  post-mortem  examinations  of  young- 
children,  and  whose  views  of  the  lesion  are  influenced  by  the  ex- 
pression lobular,  are  ajjt  to  suppose  that  there  is  an  alternation  of 
inflamed  and  healthy  lobules,  so  that  the  surface  of  the  lung  pre- 
sents an  appearance  not  unlike  mosaic  work.  This  is  a  mistake. 
Although  an  entire  lobe  is  seldom  inflamed  as  in  croupous  pneu- 
monitis, the  inflammation  commonly  extends  over  more  or  fewer 
contiguous  lobules,  but  we  find  certain  lobules  in  the  midst  of  the 
inflamed  area,  which  are  but  slightly  afiiected  or  have  escaped 
entirely.  The  extent  of  the  inflammation  is  ordinarily  from  one 
to  three  inches,  but  I  have  seen  a  nodule  of  true  catarrhal  pneu- 
monia not  larger  than  a  pea,  while  every  other  portion  of  the  lung- 
was  healthy.  On  the  other  hand,  almost  an  entire  lobe  may  appear 
hepatized  to  the  naked  eye  as  in  the  croupous  inflammation,  but 
by  a  careful  examination  certain  lobules  will  be  found  unafiected. 
Thus,  in  a  case  in  the  JSTursery  and  Child's  Hospital,  in  which 
death  occurred  at  the  age  of  one  year  from  pneumonitis  supervening 
upon  pertussis,  an  entire  lower  lobe,  with  the  exception  of  a  little 
of  its  anterior  border,  presented  the  appearance  and  feel  of  red  hepa- 
tization, but  a  careful  microscopic  examination  revealed  not  only 


496  PNEUMONITIS. 

the  absence  of  fibrin  in  the  exudate,  showing  the  catarrhal  nature 
of  the  inflammation,  but  also  certain  lobules  in  the  midst  of  the 
inflamed  lunor  which  were  not  involved. 

The  first  change  occurring  in  a  lung  invaded  by  catarrhal 
pneumonitis  is  congestion,  whether  active,  as  in  the  common  form 
of  the  disease,  in  which  the  inflammation  has  extended  into  the 
lung  from  the  bronchioles,  or  passive,  as  when  the  inflammation 
results  from  hypostasis  or  collapse.  An  exudation  of  serum,  but 
not  of  fibrin,  follows,  and  soon  the  epithelial  layer  which  lines  the 
alveoli  begins  to  swell.  The  nuclei  of  the  epithelial  cells  divide, 
the  cells  themselves  forming  large  round  cells  with  vesicular 
nuclei.  These  cells,  to  which  the  solidification  of  the  lung  is 
mainly  due,  are,  therefore,  on  account  of  their  origin  and  appear- 
ance, regarded  as  epithelial.  The  alveoli  in  catarrhal  pneumonitis, 
it  is  seen,  are  filled  with  an  inflammatory  product  quite  diflferent 
from  that  in  the  croupous  inflammation. 

Inflammation  of  the  pleura  over  the  inflamed  lung,  so  common 
in  croupous  pneumonia,  and  which  gives  it  the  name  pleuro- 
pneumonia, by  which  it  is  sometimes  designated,  rarely  occurs  in 
this  disease.  The  seat  of  this  inflammation  is  ordinarily  the 
posterior  part  of  the  lungs,  even  when  it  results  from  extension  of 
the  inflammation  from  the  bronchial  tubes.  TVhen  resulting  from 
collapse,  it  aifects  chiefly  those  lobules  which  are  remote  from  the 
bronchi,  and  which  the  air  enters  only  by  a  long  circuit. 

Catarrhal  pneumonitis,  when  it  arises  from  extension  of  acute 
inflammation  of  the  bronchioles,  is  acute,  but  in  those  forms  of  the 
disease  which  supervene  upon  passive  congestion  it  is  subacute. 
The  alveoli  are  less  distended  by  inflammatory  products  than  in 
croupous  pneumonia,  not  only  from  the  absence  of  fibrin,  but  from 
a  less  amount  of  cells.  Hence  the  volume  of  the  inflamed  lung  is 
not  so  great  as  in  that  disease,  and  the  torn  surface,  even  in  the 
adult,  does  not  present  a  granular  appearance.  Hence,  also,  the 
stage  of  gray  hepatization  does  not  supervene  so  uniformly  and 
regularly,  since  there  is  less  compression  of  the  capillaries  in  the 
alveolar  walls,  and  the  mutual  pressure  of  the  inflammatory  pro- 
ducts is  less.  In  infants  who  have  died  with  this  form  of  pneu- 
monitis, of  six  or  eight  weeks'  duration,  it  is  not  unusual  to  find 
the  afi'ected  lobules  still  in  the  stage  of  red  hepatization.  Cell 
proliferation  occurs  in  the  bronchioles  of  the  inflamed  lung  as  in 
the  alveoli,  producing  within  them  numerous  plugs,  which,  though 
they  obstruct  the  entrance  of  air,  are  not  so  firm  as  in  croupous 
pneumonitis,  as  they  are  destitute  of  fibrin. 


CHEESY    PNEUMONITIS.  497 

In  favorable  cases  the  lung  aftected  by  catarrhal  inflammation 
returns  to  its  normal  estate,  probably  by  the  same  process  as  in 
croupous  pneumonitis.  In  other  cases,  especially  in  scrofulous  and 
feeble  children,  the  inflammation  instead  of  resolving  passes  into 
what  is  now  designated  cheesy,  or  by  certain  writers  scrofulous, 
pneumonitis. 

CnEESY  Pneumonitis. — Cheesy  degeneration  of  the  inflammatory 
product  occasionally  occurs  in  the  croupous  form  of  inflamniation, 
but  it  is  more  common  in  the  catarrhal.  I  have  most  frequently 
observed  it  in  ISTew  York  during  epidemics  of  measles,  when  this 
form  of  pneumonitis  supervened  upon  the  catarrhal  bronchitis  of 
that  disease.  Cheesy  pneumonitis  is  in  its  nature 'chronic,  and 
attended  with  great  reduction  of  the  vital  powers. 

Cheesy  degeneration  of  the  exudate  or  infiltrate  consists  essen- 
tially in  the  absorption  of  the  liquid  portion,  and  fatty  degenera- 
tion of  the  solid.  The  obstruction  of  the  circulation  in  the 
capillaries  and  the  accumulation  of  cells  in  the  alveoli  and  bron- 
chioles which  cannot  be  expectorated,  are  conditions  which  favor 
the  cheesy  metamorphosis.  The  appearance  and  consistence  of  the 
lung  when  it  has  undergone  this  change  are  well  expressed  by  the 
term  which  is  employed  to  designate  it.  The  cheesy  mass  consists 
of  fatty,  shrivelled,  and  fragmentary  cells,  and  amorphous  matter, 
in  which  can  be  traced  the  elastic  fibres  and  larger  vessels  of  the 
parenchyma,  the  other  histological  elements  having  disappeared. 

The  caseous  mass  after  a  time  softens,  attracting  moisture  from 
the  surrounding  tissues.  The  molecular  detritus  and  the  shrivelled 
cells  are  now  suspended  in  a  liquid,  and,  like  any  dead  matter,  they 
are  irritants  to  the  surrounding  lung  substance.  The  bronchial 
tube  which  supplies  the  diseased  lobule,  and  which  in  many  in- 
stances was  the  starting-point  of  the  disease,  again  becomes  per- 
vious, either  by  softening  of  the  plug  or  by  ulceration  at  a  higher 
point  upon  its  walls,  and  air  is  admitted,  which  promotes  the 
putrefactive  process  and  chemical  changes  of  the  caseous  substance. 

The  lesion  now  described  is  that  of  pulmonary  consumption,  a 
disease  not  infrequent  in  children  of  two  or  three  years.  There 
are  as  yet  no  tubercles,  but  the  presence  of  softening  caseous 
material  in  the  lungs  very  frequently  leads  to  their  development 
(see  Art.  Tuberculosis),  and  accordingly,  before  the  case  ends, 
clusters  of  tubercles  may  appear  in  the  connective  tissue  and  walls 
of  the  vessels  of  the  lungs  and  in  other  organs. 

In  the  subsequent  progress  of  cheesy  pneumonitis,  if  the  patient 
live  sufiiciently  long,  there  occurs  more  or  less  expectoration  of 
32 


498  pneumo:n"itis. 

the  offending  substance,  producing  a  cavity.  Around  the  cavity 
a  vascular  pyogenic  membrane  forms,  upon  which  granulations 
arise.  These  granulations,  which  produce  pus  abundantly,  and 
from  which  small  extravasations  of  blood  are  frequent,  are  gradu- 
ally transformed  into  connective  tissue.  If  the  dead  portion  is 
expectorated,  and  there  is  a  single  small  cavity,  the  child  may 
recover,  the  empty  space  being  finally  filled  up  by  the  extension  of 
the  granulations,  and  the  production  of  a  cicatrix,  which  contracts, 
producing  a  puckered  appearance.  Ordinarily,  however,  there  are 
several  depots  of  cheesy  matter,  and  several  cavities  resulting, 
which  continue  to  enlarge  by  the  continued  softening  of  cheesy 
matter  in  therir  walls.  Often,  also,  certain  of  the  cavities  intercom- 
municate. The  bronchial  glands  undergo  hyperj^lasia,  and  certain 
of  them  are  apt,  also,  to  become  cheesy.  As  the  disease  advances, 
the  suppuration  and  expectoration  increase.  The  fatal  result 
occurs  sooner  in  children  than  in  adults,  and,  therefore,  the  lesions, 
destructive  and  inflammatory,  observed  at  autopsies,  are  ordinarily 
not  so  far  advanced  in  the  former  as  in  the  latter.  Other  unfavor- 
able changes  may  occur  in  the  hepatized  lung,  but  cheesy  degene- 
ration is  the  most  common  and  noteworthy. 

Whether  it  is  possible  to  inflate  a  lung  which  presents  to  the 
naked  eye  the  appearance  of  pneumonitis,  has  long  been  regarded  as 
a  reliable  sign  of  the  presence  or  absence  of  inflammatory  consoli- 
dation. The  facts  as  regards  the  possibility  of  insufliation  are 
these:  In  croupous  pneumonitis,  when  it  has  passed  beyond  the  first 
stage,  insufflation  is  impossible  in  the  lung  of  the  child  as  well  as 
adult,  with  the  utmost  force  of  the  breath.  "We  produce  emphy- 
sema in  healthy  portions  of  the  lungs,  while  the  inflamed  area  is 
not  encroached  upon. 

On  the  other  hand,  in  catarrhal  pneumonitis,  which  we  have  seen 
is  the  common  form  of  pulmonary  inflammation  in  children  under 
the  age  of  five  or  six  years,  and  in  which  there  is  less  distension  of 
the  air  cells  by  inflammatory  products,  the  lung  can  be  inflated,  ex- 
cept in  protracted  cases,  but  when  fully  inflated  the  solidified  lobules 
can  still  be  felt  between  the  thumb  and  fingers.  In  protracted 
catarrhal  pneumonitis,  as  well  as  in  protracted  collapse,  which,  in- 
deed, may  and  often  does  become  a  pneumonitis,  full  inflation  is 
impossible.  Central  portions  still  remain  impervious  to  air.  While, 
therefore,  the  possibility  or  impossibility  of  inflating  a  lung  re- 
moved from  an  adult,  and  which  presents  to  the  naked  eye  the 
appearance  of  pneumonic  solidification,  is  a  valuable  sign  as  in- 


SYMPTOMS.  499 

dicatiiif^  wlietlier  or  not  the  disease  was  pneumonitis,  in  tlic  child 
little  importance  can  be  attached  to  it. 

Symptoms. — Croupous  pneumonitis  commonly  begins  abruptly, 
or  it  is  preceded  for  a  brief  period  by  symptoms  of  a  cold.  In  the 
adult,  the  abrupt  commencement  is  ordinarily  with  a  chill.  In 
the  child,  there  is  often  a  sensation  of  chilliness,  but  a  distinct 
chill  is  not  common.  Convulsions  sometimes  occur  in  place  of  a 
chill.  Catarrhal  pneumonitis,  being  ordinarily  a  secondary  disease, 
begins  in  a  more  gradual  way,  its  symptoms  being  preceded  by,  and 
associated  with,  those  of  the  primary  affection. 

The  symptoms  of  acute  pneumonitis,  whether  catarrhal  or 
croupous,  are  the  following:  Anorexia,  thirst,  restlessness,  elevation 
of  temperature,  acceleration  of  pulse  according  to  the  intensity  of 
the  inflanmiation  and  the  feebleness  of  the  patient,  flushed  face,  a 
countenance  indicative  of  suffering,  accelerated  respiration,  with 
an  expiratory  moan.  These  symptoms  are  constant  in  the  acute 
inflammation  unless  of  the  mildest  form.  Those  which  are  im- 
portant I  shall  describe  more  fully. 

The  expiratory  moan  is  described  by  writers  as  a  pathognomonic 
symptom  of  this  disease,  or  of  pleurisy.  It  is  evidently  due  to  the 
pain  experienced  by  the  friction  of  the  inflamed  pleura.  As  a  rule, 
the  expiratory  moan  does  indicate  either  pneumonitis  or  simple 
pleuritis ;  but  there  are  exceptions.  It  may  occur,  for  example, 
from  indigestible  substances  in  the  stomach  and  intestines,  giving 
rise  to  acute  dyspepsia;  or  from  certain  forms  of  abdominal  inflam- 
mation, w^iicli  render  movements  of  the  diaphragm  painful. 

The  cough  in  the  first  days  of  pneumonitis  is  often  dry  or  hacking 
and  painful.  It  afterwards,  if  the  case  is  fsxvorable,  becomes  looser, 
and  is  painless.  We  very  seldom  observe -in  the  child  the  bloody 
sputum  which  characterizes  pneumonitis  in  the  adult,  since  in 
catarrhal  inflammation  there  is  little  or  no  exudation  of  blood 
corpuscles.  The  sputum,  which  in  this  form  of  the  disease  is  the 
product  of  secretion  and  cell  proliferation,  is  at  first  thin  and  frothy, 
but  afterwards  thicker  and  less  tenacious  from  the  greater  number 
of  cells.  There  is  often,  in  the  first  period  of  the  inflammation, 
pretty  severe  and  constant  headache,  the  patient  complaining  of 
the  head,  if  old  enough  to  speak,  before  he  does  of  the  chest.  In 
a  severe  attack  the  child  at  this  period  lies  with  the  eyes  shut,  ap- 
parently in  a  half-conscious  state,  fretful  if  spoken  to  or  aroused, 
so  that  the  physician  might  be  led  to  suspect  the  presence  of  cere- 
bral disease.  If  there  is  vomiting,  accompanied  with  sudden 
twitching  of  the  muscles,  and  convulsions — symptoms  which  some- 


500  PNEUMONITIS. 

times  occur — the  liability  to  error  in  diagnosis  is  greatly  increased. 
Cerebral  symptoms  are  more  prominent  in  the  commencement  of 
pneumonitis  than  subsequently.  As  the  disease  advances  they 
subside,  and  symptoms  referable  to  the  chest  become  more  con- 
spicuous. 

The  breathing  is,  as  I  have  said,  accelerated.  Thirty  or  forty 
respirations  per  minute  are  common,  and,  in  severe  cases,  the  num- 
ber reaches  sixty  or  even  eighty.  In  infants  there  is  greater  fre- 
quency of  resi^iration  than  in  children.  In  those  at  the  breast,  if 
the  dyspncea  is  urgent,  nutrition  is  sometimes  seriously  interfered 
with,  since  in  these  severe  cases  respiration  is  performed  more 
through  the  mouth  than  nostrils,  so  that  if  the  infant  seizes  the 
nipple,  it  is  forced  to  relinquish  it  in  order  to  breathe.  Dilatation 
of  the  alse  nasi,  and  depression  of  the  infra-mammary  region,  accom- 
pany inspiration.  The  dyspnoea  in  catarrhal  pneumonitis  is  often 
due  in  great  part  to  accompanying  bronchitis. 

The  temperature  in  mild  cases  of  pneumonitis  is  elevated  to 
about  101°  to  103°  ;  in  severe  cases  it  may  reach  105°  or  even  107°, 
the  former  being  the  highest  observed  by  Mr.  Squire.  In  ninety- 
seven  observations  made  by  M.  Roger,  the  average  temperature 
was  104°  during  the  active  period  of  the  inflammation.  The  face 
is  therefore  flushed,  and  the  heat  of  surface  pungent,  except  in 
weakly  children,  in  whom,  even  in  severe  and  active  inflammation, 
the  face  is  sometimes  pale,  and  the  extremities  of  natural  or  less 
than  natural  temperature. 

The  tongue  is  moist,  and  covered  with  a  light  fur ;  the  thirst  is 
such  that  nutriment  may  be  given  in  the  form  of  drinks,  when  the 
loss  of  appetite  prevents  the  use  of  solid  food.  The  bowels  are 
usually  constipated.  The  secretions,  in  the  first  and  second  stages, 
are  diminished.  The  urine  is  more  deeply  colored  than  in  health, 
and  in  vigorous  patients  it  deposits  ]jrates  on  cooling.  The  chlo- 
rides are  also  deficient,  or  absent;^  from  the  urine,  as  long  as  the 
inflammation  is  extending. 

In  favorable  cases,  in  from  seven  to  ten  days  the  heat  and  thirst 
decline ;  the  pulse  and  respiration  gradually  become  less  frequent ; 
the  cough  looser ;  the  features  have  a  more  placid  or  contented 
expression  ;  the  appetite  returns,  and  the  patient  is  again  amused 
^y  playthings.  The  improvement  is  progressive,  but  gradual.  A 
slight  cough  is  occasionally  observed  for  two  or  three  weeks  after 
convalescence  is  fully  established. 

Death  in  the  acute  stage  of  the  inflammation  commonly  occurs 
from  asthenia.     The  pulse  gradually  becomes  more  frequent  and 


PHYSICAL    SIGNS.  501 

feeble,  the  respiration  more  oppressed,  and  finally,  as  death  ap- 
proaches, the  face  and  extremities  become  cool.  Occasionally  death 
results  from  apncca,  due  in  great  part  to  coexisting  bronchitis.  In 
exceptional  instances  it  occurs  from  convulsions,  followed  by  coma, 
especially  in  the  first  week.  Death,  in  those  protracted  cases  in 
which  the  inflammatory  products  have  undergone  cheesy  degene- 
ration, is  usually  from  asthenia. 

Such  are  the  symptoms  and  progress  of  ordinary  acute  pneumo- 
nitis in  children.  When  the  inflammation  is  subacute,  as  in  those 
forms  of  the  disease  which  result  from  collapse  or  hypostasis,  the 
symptoms  are  less  pronounced.  The  respiration  in  such  cases  is 
but  moderately  accelerated,  is  attended  by  little  pain,  and  therefore 
the  expiratory  moan  is  often  absent.  An  occasional  short,  dry 
cough  occurs,  with  so  little  increase  of  temperature  and  quicken- 
ing of  the  pulse  that  the  pneumonitis  is  apt  to  be  overlooked  by 
the  physician,  the  symptoms  being  referred  to  bronchitis.  Pleuri- 
tis  does  not  occur  in  connection  with  this  form  of  pneumonitis,  ex- 
cept when  a  small  abscess  or  gangrene  occurs  in  an  aflected  lobule 
directly  under  the  pleura.     A  few  such  cases  I  have  observed. 

Tubercular  pneumonitis  extends  over  much  or  little  of  the  lung 
according  to  the  amount  of  tubercles.  The  symptoms  are  like 
those  of  severe  primary  pneumonitis,  superadded  to  such  as  pertain 
to  tuberculosis.  This  inflammation,  when  once  established  in  the 
consumptive  child,  commonly  continues  till  the  close  of  life.  I 
have  sometimes  had  these  cases  under  observation  for  several 
consecutive  weeks,  even  months,  and  during  the  whole  time  there 
was  not  only  acceleration  of  pulse  and  respiration,  but  the  expira- 
tory moan.  As  regards  pneumonitis  occurring  in  hooping-cough, 
it  is  an  interesting  fact  that  its  symptoms  modify  those  of  the 
primary  disease,  so  that,  during  the  active  period  of  the  inflamma- 
tion, the  paroxysmal  cough  diminishes,  and  a  short,  hacking  cough 
and  expiratory  moan  occur  in  place.  As  the  inflammation  abates, 
the  spasmodic  cough  returns.  Pneumonitis,  occurring  in  measles, 
is  more  obstinate,  protracted,  and  dangerous  than  the  primary 
form.  It  usually  commences  about  the  period  of  the  decline  of 
the  eruption,  and,  in  favorable  cases,  continues  two  or  three  weeks. 
It  is  then  a  sequel,  rather  than  complication. 

Physical  Signs. — The  physical  signs  of  pneumonitis  in  infancy 
and  ctiildhood  are  the  same  as  in  the  adult,  but  in  a  large  propor- 
tion of  cases  they  are  less  distinct.  In  a  majority  of  patients 
under  the  age  of  three  years  the  crepitant  rule  is  not  observed. 
This  is  due  to  the  small  size  of  the  air  vesicles  at  this  age.    I  have 


502  PNEUMONITIS. 

now  and  then  detected  it  in  quite  young  children,  in  whom  it  is 
a  finer  rale  than  in  the  adult.  If  observed,  it  is,  of  course,  positive 
proof  of  the  existence  of  pneumonitis.  The  physical  signs,  there- 
fore, in  the  first  stao-e  of  the  inflammation  are  often  obscure  in 
consequence  of  the  absence  of  the  pathognomonic  rale.  The  vesicu- 
lar murmur  is  somewhat  intensified  through  the  chest,  and  there 
is  in  this  stage  slight  dulness  on  percussion  over  the  seat  of  the 
inflammation  due  to  engorgement  of  the  vessels,  but  it  is  difiicult 
to  appreciate  this. 

In  the  second  stage,  which  supervenes  more  or  less  rapidly,  the 
physical  signs  are  more  distinct.  Bronchial  respiration  is  in  most 
cases  detected,  higher  in  pitch  than  the  vesicular  murmur,  with 
the  sound  of  expiration  higher  than  that  of  inspiration.  The  voice 
of  the  patient  is  transmitted  to  the  ear  applied  over  the  seat  of  the 
disease,  and  often  a  peculiar  vibratory  sensation  is  communicated 
to  the  hand  applied  over  the  part,  so  that  it  is  possible  to  locate 
the  disease  by  palpation  alone.  There  are  frequently,  in  the  second 
stage,  and  sometimes  in  the  first,  coarse  mucous  rales  in  various 
parts  of  the  chest  from  coexisting  bronchitis. 

Percussion,  in  the  second  stage,  elicits  a  dull  sound  as  compared 
with  that  produced  on  the  opposite  side  of  the  chest.  The  dulness 
corresponds  in  extent  with  the  solidification,  and  with  the  bronchial 
respiration. 

As  the  inflammation  abates,  the  dulness  on  percussion  gradually 
diminishes,  and  the  bronchial  respiration  is  succeeded  by  the 
subcrepitant  rale.  Often,  for  a  considerable  period  after  convales- 
cence is  established,  moist  rales  are  observed  in  the  chest,  and 
sometimes  the  dulness  on  percussion  does  not  entirely  disappear 
till  after  the  health  is  fully  restored. 

In  catarrhal  pneumonitis  the  physical  signs  are  not  so  distinct. 
This  is  due  in  part  to  the  limited  extent  of  the  inflammation,  in 
part,  in  many  cases,  to  its  subacute  character,  and  in  part  to  the 
fact  that  this  inflammation  is  apt  to  be  double,  especially  in  those 
frequent  cases  in  which  the  cause  of  the  disease  is  hypostatic 
congestion. 

Diagnosis. — In  the  adult,  pneumonitis  is  a  diseaseof  easy  diagnosis. 
In  infancy  and  childhood,  on  the  other  hand,  diagnosis  is  often 
difficult.  Acute  primary  pneumonitis  in  young  children  is  apt  to 
be  confounded  with  mening-itis  or  one  of  the  essential  fevers  if  the 
examination  be  made  within  the  first  or  second  day.  In  children 
over  the  age  of  three  or  four  years,  it  is  most  frequently  mistaken 
for  remittent  fever.     The  two  diseases  do,  as  regards  symptoms. 


DIAGNOSIS.  503 

resemble  each  other.  Both  are  characterized  by  great  elevation  of 
temperature,  rapid  pulse,  languor,  and  drowsiness,  and  in  both 
there  is  apt  to  be  a  cough  even  from  the  first  day.  But  remittent 
fever  (I  include  for  the  present  under  this  term  also  typhoid  fever) 
usually  begins  more  gradually  than  pneumonitis.  It  is  preceded 
for  a  few  days  by  sym[)tom8  of  mild  indisposition,  though  there 
are  exceptions,  and  it  may  commence  quite  abruptly.  The  expira- 
tory moan  occurring  in  pneumonitis  in  most  cases  by  the  second 
or  third  day  is  a  symptom  of  great  diagnostic  value.  But  positive 
proof  of  the  nature  of  the  disease  is  afforded  only  by  auscultation 
and  percussion.  Scarlet  fever,  in  its  commencement,  bears  some 
resemblance  to  acute  primary  pneumonitis.  The  points  of  diffier- 
ential  diagnosis  are  the  redness  of  the  buccal  membrane  and  the 
fauces,  and  the  efflorescence  upon  the  skin  in  scarlet  fever  on  the 
one  hand,  and  on  the  other  the  rational  and  physical  signs  of 
pneumonitis,  which  have  been  described. 

Greater  difficulty  attends  the  diagnosis  of  acute  pneumonitis 
from  bronchitis  and  pleuritis.  The  presence  of  the  expiratory 
moan,  if  it  is  pretty  constant  and  marked,  is  sufficient  to  exclude 
bronchitis,  unless  as  a  complication,  but  the  physical  signs  con- 
stitute the  only  reliable  means  of  exact  diagnosis.  The  presence 
or  absence  of  bronchitis  is  readily  determined  hy  auscultation. 
The  physical  signs  should  be  carefully  noted,  in  order  to  deter- 
mine if  there  is  some  point  of  solidification. 

Solidification  gives  rise  to  dulness  on  percussion,  bronchial 
respiration,  and  bronchophony.  These  three  signs  coexisting 
afford  sufficient  proof  of  pneumonitis,  unless  there  is  tubercular 
consolidation  or  possibly  collapse  supervening  on  suffocative  bron- 
chitis. The  history  of  the  case  aids  in  determining  whether  there 
is  either  of  these  diseases.  Moreover,  collapse  occurs  later  after 
the  attack  commences  than  hepatization,  and  does  not  produce  so 
distinct  bronchophony  or  bronchial  respiration  as  are  observed  in 
the  common  form  of  pneumonitis. 

Pleuritis  with  eff"usion  may  present  physical  signs  which  bear 
considerable  resemblance  to  those  in  pneumonia ;  but  in  pneumonia, 
except  when  associated  with  tubercular  deposit,  the  dulness  on 
percussion  is  not  so  great  as  that  from  pleuritic  eff'usion,  nor  does 
the  line  of  dulness  vary  according  to  the  j)osition  of  the  child.  In 
pleuritic  eff'usion  in  a  young  child,  the  respiratory  murmur  can 
often  be  heard  with  the  ear  applied  over  the  liquid,  but  it  is 
indistinct,  and  transmitted  through  the  liquid  from  a  distance. 
The  practised  ear  is  able  to  discover  the  difference  between  it  and 


504  PNEUMONITIS. 

the  bronchial  respiration  of  pneumonitis.  Attention  to  these  facts 
enables  us  to  make  a  positive  differential  diagnosis  in  most  cases. 
Occasionally  the  physical  signs  indicate  the  coexistence  of  pneu- 
monitis and  pleuritis. 

In  catarrhal  pneumonitis,  it  is  often  difiicult  to  determine  cer- 
tainly the  nature  of  the  disease,  since  the  physical  signs,  if  there 
is  but  little  extent  of  inflammation,  are  absent  or  indistinct.  I 
have  often,  in  post-mortem  examinations,  found  so  small  a  part  of 
the  lung  hepatized  that  it  could  not  possibly  have  produced  any 
appreciable  dulness  on  percussion,  bronchial  respiration,  or  bron- 
chophony. Such  cases  are  apt  to  pass  for  bronchitis,  and,  practi- 
cally, this  matters  little,  since  the  treatment  required  by  the  two  is 
not  dissimilar. 

Prognosis. — Primary  pneumonitis,  aflfecting  only  one  lung,  if 
properly  treated,  in  most  instances  terminates  favorably  in  children , 
and  even  in  infants.  If  double,  it  is,  as  in  the  adult,  much  more 
serious,  and,  in  a  large  proportion  of  cases,  fatal.  Secondary 
pneumonitis,  pneumonitis  occurring  in  measles,  hooping-cough, 
tuberculosis,  or  resulting  from  hypostatic  congestion  in  the  course 
of  some  exhausting  disease,  is,  on  the  other  hand,  more  frequently 
fatal.  As  death  usually  occurs  from  asthenia,  the  younger  the 
child,  and  more  feeble  the  constitution,  the  greater  the  danger. 

Unfavorable  symptoms  are  a  pulse  becoming  more  and  more 
frequent  and  feeble,  pallor  of  countenance,  inability  of  the  patient 
to  support  the  head,  total  loss  of  appetite,  refusal  to  notice  or  be 
amused  by  playthings,  absence  of  tears  when  crying — a  symptom 
which  the  French  writers  have  pointed  out — and  the  appearance 
of  pemphigus  on  the  face  or  elsewhere. 

Indications  on  which  a  favorable  prognosis  may  be  based  are 
moderate  acceleration  of  pulse,  pneumonitis  primary  and  limited  to 
one  side,  ability  to  support  the  head  or  sit  erect,  being  amused  by 
playthings,  etc. 

Treatment. — The  treatment  of  the  two  forms  of  pneumonitis, 
croupous  and  catarrhal,  the  former  for  the  most  part  primary  and 
acute,  and  the  latter  secondary  and  often  subacute,  requires  to 
be  considered  separately,  as  much  as  do  their  symptoms  and 
anatomical  characters.  In  croupous  pneumonitis,  if  seen  at  the 
commencement  or  within  a  few  hours  of  the  commencement,  an 
emetic  of  ipecacuanha  may  be  given,  as  recommended  by  Trousseau. 
This  acts  promptly  as  a  cardiac  sedative,  diminishing  somewhat 
the  afflux  of  blood  towards  the  lungs,  and  moderating  the  inflam- 


TREATMENT.  505 

niation.      It    should    never   be   employed   except   at    the   period 
mentioned. 

If  the  previous  health  of  the  patient  has  been  good,  his  age  above 
three  years,  and  if  the  inflammation  is,  in  part  at  least,  in  the  first 
stage,  aconite  or  veratrum  viride,  properly  employed,  is  serviceable. 
Either  one  is  an  eflicient  substitute  for  bloodletting.  Some  prefer 
aconite  as  less  depressing  than  veratrum,  and  it  is  known  to  be  a 
favorite  remedy  of  homoeopath ists.  I  have  ordinarily  employed 
the  veratrum,  prescribing  the  tincture  in  doses  of  one  drop  every 
three  hours  to  a  child  of  five  years.  It  can  be  given  dropped  in 
sweetened  water  or  in  the  syrup  of  tolu.  Its  effect  should  be  care- 
fully watched,  and  it  should  be  omitted,  or  given  less  frequently, 
when  the  pulse  is  reduced  to  near  the  natural  frequency.  The 
pulse  should  be  maintained  two  or  three  days,  dating  from  the 
commencement  of  the  attack,  at  about  its  natural  frequency,  but 
never  below  it. 

If  bronchial  respiration,  bronchophony,  and  dulness  on  percus- 
sion are  present,  indicating  the  second  stage ;  in  other  words,  if  it 
appear  from  the  signs  that  the  inflamed  lobe  or  lobes  are  hepatized, 
little  benefit  accrues  from  the  use  of  so  powerful  a  sedative,  and 
much  harm  may  be  done.  "When  this  medicine  is  discontinued, 
or  without  its  use,  if  the  physicitin  is  not  called  till  the  stage  of 
hepatization,  a  minute  dose  of  tartrate  of  antimony  and  potassa 
should  be  prescribed  in  the  class  of  cases  to  which  I  allude.  It 
may  be  advantageously  combined  with  sulphate  of  morphia,  if  the 
respiration  is  painful  or  cough  troublesome.  The  following  formula 
I  have  sometimes  employed  with  a  satisfactory  result,  for  a  child 
of  five  years : — 

R.  Morph.  sulpli., 

Antim.  et  potas.  tart,  aa  gr.  j  ; 
Syr.  bal.  tolut.  ^^iv.     Misce. 

Dose,  one  teaspoonful  from  two  to  four  hours.  In  place  of  this, 
Dover's  powder  may  be  administered  in  combination  with  nitrate 
of  potash.  There  soon  arrives  a  period  when  depressing  remedies 
should  be  omitted.  Many  now  recover  with  simple  mucilaginous 
drinks  or  mild  expectorants,  like  syrup  of  squills  or  ipecacuanha 
in  small  doses.  Others  require  more  sustaining  measures,  and  for 
such  carbonate  of  ammonia  with  the  syrup  or  decoction  of  senega 
is  preferable. 

The  treatment  described  above  is  proper  only  for  robust  children 
with  primary  pneumonitis.  In  no  other  cases  are  measures  so 
depressing  required.     There  can  be  no  doubt  that  the  great  error, 


506  PNEUMONITIS. 

in  the  therapeutic  management  of  children  with  this  disease,  has 
been  the  employment  of  medicines  which  reduced  the  strength, 
when  gentler  measures,  or  those  of  a  sustaining  nature,  were 
required.  In  secondary  pneumonitis  or  primary  if  the  patient  is 
pallid,  scrofulous,  or  at  all  wasted,  or  under  the  age  of  three  years, 
neither  aconite,  veratrum  viride,  nor  antimony  should  be  given. 
Such  cases  require  milder  therapeutic  agents,  as  syrup  of  squills 
or  ipecacuanha  in  the  first  stages,  and,  subsequently,  carbonate  of 
ammonia  with  senega.  Some  are  best  treated  with  ammonia  and 
senega  from  the  commencement. 

The  bowels  should  be  kept  open,  as  an  important  part  of  the 
treatment  of  croupous  pneumonitis  in  its  first  stages.  A  small 
dose  of  castor  oil,  Rochelle  salts,  or  citrate  of  magnesia  should  be 
given  if  there  is  any  tendency  to  constipation,  and  repeated  from 
time  to  time  if  required.  A  saline  aperient  by  its  derivative  and 
refrigerant  effect  in  some  cases  obviates  the  necessity  of  employing 
cardiac  sedatives. 

Local  treatment  is  required  in  all  cases;  counter-irritation 
should  be  produced  as  soon  as  possible  over  the  inflamed  lobe,  by 
mustard,  iodine,  or  some  stimulating  liniment,  and,  except  at  the 
time  of  this  application,  the  chest  should  be  constantly  covered 
with  an  emollient  poultice,  or  with  a  cloth  wrung  out  of  warm 
water  and  covered  with  oil-silk.  I  prefer,  however,  the  constant 
application,  under  the  oil-silk,  of  the  following  poultice,  made  large 
but  thin  as  the  cover  of  a  book  and  therefore  light. 

^.  Pulv.  sinapis.  .fss; 

Pulv.  semin.  lini  §viij.     Misce. 

In  a  large  proportion  of  cases,  vesication  is  not  required.  If  the 
inflammation  is  extensive,  and  the  symptoms  urgent,  it  is  occa- 
sionally advisable  to  blister,  and  the  cantharidal  collodion  should 
be  used  for  this  purpose.  A  safe,  almost  painless,  and  at  the  same 
time  efiScient,  mode  of  applying  this  is  in  spots  as  large  as  a  ten 
cent  piece,  half  a  dozen,  more  or  fewer  according  to  the  extent  of 
the  inflammation,  the  skin  of  course  remaining  sound  between 
them.  This  mode  of  application  obviates  the  danger  of  producing 
a  troublesome  sore,  which  sometimes  occurs  in  children  from  the 
ordinary  mode  of  vesication. 

The  diet  should  be  nutritious,  consisting  of  animal  broths  and 
the  like,  unless  during  the  first  three  or  four  days,  in  robust  chil- 
dren. 

In  those  few  cases  of  croupous  pneumonitis  which  occur  in 
young  children,  no  remedy  should  be  employed  more  depressing 


PLEURITIS.  507 

than  ipccacuaiilia,  perhaps  combined  with  some  aperient  like 
castor  oil,  as  in  the  formula  recommended  in  the  treatment  of 
bronchitis. 

Before  leaving  the  subject  of  the  therapeutics  of  pneumonitis, 
I  desire  to  impress  u])on  the  reader  the  paramount  importance  of 
ascertaining  fully,  before  he  prescribes,  not  only  the  extent  and 
stage  of  the  inflammation,  but  especially  the  condition  of  the 
patient's  constitution.  For  many  cases  require  sustaining  measures 
from  the  first,  and,  without  a  proper  appreciation  of  the  patient's 
state,  the  medicines  ordered  may  be  highly  injurious  instead  of 
useful. 

Catarrhal  pneumonitis  requires  somewhat  different  treatment, 
not  only  because  it  occurs  chiefly  in  infancy  and  early  childhood 
when  there  is  little  vigor  of  constitution,  but  because  it  is  as  a 
rule  secondary.  In  acute  catarrhal  pneumonitis,  which,  as  we  have 
seen,  in  most  instances  results  from  an  active  bronchial  inflamma- 
tion, the  treatment  already  employed  for  the  primary  disease  should 
be  continued.  (See  Art.  Bronchitis.)  If  there  is  pain  or  restless- 
ness, a  little  opiate  should  be  added.  In  subacute  forms  of  the 
disease,  and  in  the  acute  when  it  has  continued  a  few  days,  sus- 
taining and  even  stimulating  measures  are  indicated;  carbonate 
of  ammonia  with  some  tonic  is  useful  in  such  cases. 

In  cheesy  pneumonitis,  or  in  protracted  catarrhal  pneumonitis 
which  may  or  may  not  have  become  cheesy,  carbonate  of  ammo- 
nia in  combination  with  citrate  of  iron  and  ammonia,  equal  parts, 
or  cod-liver  oil  to  which  two  or  three  drops  of  syrup,  ferri  iodidi 
are  added,  will  be  found  useful,  as  are  also  alcoholic  stimulants. 
ISTutritious  diet  is  required  in  all  cases  of  catarrhal  pneumonitis. 
The  local  treatment  should  consist  of  an  oil-silk  jacket  and  coun- 
ter-irritation, as  recommended  in  the  treatment  of  croupous  pneu- 
monitis, without  vesication.  In  case  of  hypostatic  pneumonia  the 
position  of  the  patient  should  be  frequently  changed. 


CHAPTER    VI. 


PLEURITIS. 


Pleuritis  occurs  both  as  a  primary  and  secondary  disease.  If 
we  except  such  cases  as  are  due  to  pneumonitis  and  tubercles,  secon- 
dary pleurisies  are  more  common  in  children  than  in  adults. 


508  PLEUKITIS. 

Causes. — The  ordinary  cause  of  primary  pleuritis  is  the  same  as 
that  of  most  primary  inflammations,  namely,  the  impression  of  cold. 
It  is  therefore  most  commoa  in  the  cold  months,  and  in  times  of 
changeable  temperature.  Cachexia  is  a  predisposing  cause.  There- 
fore, children  whose  blood  is  impoverished  by  the  anti-hygienic 
conditions  in  which'  they  reside,  or  by  previous  disease,  are  more 
liable  to  it  than  those  who  have  robust  constitutions.  Hence,  also, 
its  frequency  among  foundlings  and  the  cT:iildren  of  the  city  poor. 

The  causes  of  secondary  pleuritis  are  quite  numerous.  The  most 
common,  after  the  age  of  three  years,  are  tubercles,  pneumonitis, 
and  scarlet  fever.  Tubercles  cause  pleuritis  by  their  irritating 
effect  upon  the  pleura,  and  of  course  only  those  tubercles  can 
produce  this  result  which  are  seated  directly  underneath  this 
membrane.  Pneumonitis  causes  pleurisy  by  extension  of  the  in- 
flammation. Scarlet  fever  gives  rise  to  it  indirectly  as  a  sequel. 
In  a  certain  proportion  of  cases  of  this  exanthem,  during  the  period 
of  desquamation  or  convalescence,  active  congestion  or  inflamma- 
tion of  the  kidneys  occurs,  giving  rise  to  ursemia.  Urea  in  the 
blood  is  an  irritant  to  serous  structures,  and  hence  is  a  not  infre- 
quent cause  of  pleuritis. 

In  the  infant  many  cases  of  pleuritis  are  due  to  the  escape  or 
discharge  into  the  pleural  cavity  of  some  pathological  product, 
usually  pus,  softened  tubercle,  or  decomposed  lung  tissue.  This 
substance  is  an  irritant,  and  it  produces  acute  and  often  general 
pleuritis.  A  very  small  amount  of  pus  or  softened  tubercle,  or  of 
decomposed  lung  escaping  into  the  pleural  cavity,  gives  rise  to 
violent  and  fatal  pleurisy.  I  have  made  post-mortem  examinations 
of  several  such  cases. 

A  retro-pharyngeal  abscess  in  rare  instances  descends  behind 
the  pharynx  and  oesophagus,  and  opens  into  one  of  the  pleural 
cavities,  causing  fatal  pleuritis.  A  suppurated  bronchial  gland,  or 
an  abscess  in  the  walls  of  the  chest,  occasionally  produces  the 
same  result.  In  January,  1864,  I  presented  to  the  'New  York 
Pathological  Society  the  lungs  of  an  infant  with  the  following 
history:  R.,  nine  months  old,  of  German  parentage,  family  scro- 
fulous. Its  own  health  was  good  prior  to  the  sickness  of  which 
it  died,  and  it  was  fleshy.  The  only  other  child  in  the  family,  a 
girl,  had  suffered  from  strumous  ophthalmia  and  strumous  peri- 
ostitis of  the  tibia.  This  infant  was  taken  sick  about  December 
19th,  1863,  with  moderate  febrile  movement  and  restlessness,  but 
apparently  without  any  serious  indisposition.  On  the  22d  of 
December,  the  mother  called  my  attention  to  a  prominence  just 


CAUSES.  509 

below  the  right  clavicle.  This  proved  to  be  an  abscess.  A  poultice 
was  applied,  in  the  expectation  that  it  would  discharge  externall}''. 
On  the  24th  of  December,  however,  the  prominence  subsided,  and 
immediately  the  symptoms  were  greatly  aggravated.  The  pulse 
rose  to  160  per  minute,  the  respiration  to  60  or  80,  and  expiration 
was  accompanied  by  a  moan,  so  common  in  acute  inflammation  of 
the  pleura  or  lung.  Within  a  day  or  two  after  the  disappearance 
of  the  tumor,  and  the  exacerbation  of  the  symptoms,  dulness  on 
percussion  was  observed  on  this  side,  and  this  increased  till  there 
was  perfect  flatness.  The  right  pleural  cavity  had  evidently  filled 
with  liquid,  the  acceleration  of  pulse  and  respiration  continued, 
the  patient  grew  more  and  more  feeble,  and  death  occurred  De- 
cember 31st. 

At  the  autopsy,  on  dissecting  away  the  integument  from  the 
right  side  of  the  chest,  an  abscess  was  opened,  containing  nearly 
an  ounce  of  pus,  located  at  the  point  where  the  tumor  had  been 
observed.  There  was  a  small  round  opening  from  this  abscess 
directly  into  the  cavity  of  the  chest,  so  that,  on  depressing  the  ribs, 
liquid  escaped  from  the  cavity.  On  removing  the  sternum,  the 
liquid  was  found  to  consist  mainly  of  serum  with  lymph,  and  at 
the  bottom  of  the  liquid  was  considerable  pus.  I  have  met  one 
other  case,  apparently  almost  identical  with  this,  the  infant  being 
seven  months  old,  but  I  did  not  attend  it  in  the  latter  part  of  its 
sickness.  The  abscess  in  the  case  which  I  have  detailed  was  ob- 
viously strumous,  probably  occurring  from  glandular  inflammation. 
This  mode  of  production  of  pleuritis,  namely,  by  the  discharge  of 
an  abscess  located  in  the  thoracic  walls,  is  no  doubt  rare.  It  was 
so  considered  by  the  members  of  the  Pathological  Society.  Pleu- 
ritis, which  is  a  common  accompaniment  of  croupous  pneumonitis, 
is  not  common  in  the  catarrhal  form  of  the  disease,  and  therefore 
cases  due  to  pulmonary  inflammation  are  less  frequent  in  children 
than  in  adults.  But  inflammation  of  the  pleura  occasionally 
occurs  in  catarrhal  pneumonitis  in  the  following  manner:  Little 
abscesses  are  produced  in  the  solidifled  lung,  containing  from  one 
or  two  to  as  many  as  fifteen  or  twenty  drops  of  pus,  as  has  been 
stated  in  our  remarks  on  pneumonitis.  The  pus,  approaching  the 
pleural  surface,  produces  circumscribed  pleuritis  at  that  point,  or, 
opening  into  the  pleural  cavity,  it  gives  rise  to  general  pleuritis, 
with  or  without  pneumothorax.  The  following  cases,  among  others 
which  I  could  present,  established  this  point.  These  cases  are  also 
interesting,  as  showing  the  occasional  latency  of  pneumonitis. 


510  PLEURITIS. 

Case  1. — I.  M ,  male  infant,  was  admitted  into  the  Nursery  and 

Child's  Hospital,  May  19th,  1859,  at  the  age  of  two  months.  He  was 
very  delicate  at  the  time  of  admission,  and  had  slight  bronchitis,  but, 
being  placed  with  a  wet-nurse,  he  gradually  improved.  About  the  middle 
of  July,  attacks  of  diarrhoea  occurred,  each  lasting  from  one  to  two  days, 
and  from  this  time  his  health  declined.  Furnncular  eruptions  appeared 
on  the  head  and  neck,  and,  though  sustaining  measures  were  emplo3'ed 
with  medicines  to  control  the  diarrhrea,  there  was  progressively  more 
emaciation  and  feebleness. 

The  records  on  August  1st  state,  "Continues  to  fail,  apparently  from 
the  attacks  of  diarrhoea;  the  furnncular  eruption  continues."  On  the 
3d  of  August,  he  died  suddenly  of  apnoea,  though  there  had  been  no 
s^'mptoms  to  direct  attention  to  the  chest.  Possibly  he  had  a  slight 
cough,  which  had  escaped  detection. 

Autopsy  eight  hours  after  death. — Stomach  and  jejunum  healthy  ; 
mucous  membrane  lining  the  lower  part  of  the  ileum  and  the  entire 
colon  vascular,  and  that  of  the  colon  considerably  thickened  ;  mesenteric 
glands  enlarged,  and  of  a  lighter  color  than  in  health  ;  right  lung  com- 
pressed by  a  sero-fibrinous  exudation,  so  as  to  occup}^  a  small  space, 
though  the  amount  of  liquid  was  not  more  than  two  ounces ;  nearly  the 
entire  pleura,  visceral  and  parietal,  on  this  side  was  covered  with  a  fibri- 
nous deposit  of  a  creamy  appearance.  Some  of  this  had  settled  in  the 
depending  portion  of  the  cavity.  This  lung  could  be  inflated,  except  a 
little  of  the  lower  lobe,  winch  was  hepatized. 

On  the  left  side,  the  lung  also  occupied  a  very  small  space,  being  col- 
lapsed; the  upper  lobe  could  be  readily  inflated  when  it  had  the  elasticity 
of  healthy  lung;  the  lower  lobe  had  a  healthy  appearance,  and  could  be 
inflated,  except  a  portion  in  the  posterior  aspect  measuring,  perhaps,  an 
inch  in  diameter;  this  was  partially  coated  with  lymph,  and  was  found 
to  contain  two  small  abscesses,  one  closed,  the  other  opening  externally 
on  the  surface  of  the  lung  and  internally  into  a  bronchial  tube.  On 
attempting  inflation,  the  air  passed  directly  through  this  opening.  The 
closed  abscess  contained  from  one-third  to  half  a  drachm  of  pus  cor- 
puscles, and  disintegrated  lung  tissue,  as  shown  by  the  microscope. 
The  child  was  much  emaciated. 

Case  2. — M.  I ,  female,  was  admitted  into  the  Child's  Hospital 

October  7th,  1859,  at  the  age  of  about  four  months;  at  the  time  of  admis- 
sion, was  somewhat  wasted  with  diarrhoea;  her  health  improved  [jartiall}', 
but  she  remained  feeble,  and  was  at  times  much  troubled  with  meteorism 
which  occasioned  pain. 

On  the  2d  of  November,  she  was  suddenly  seized  with  great  dyspnoea, 
which  terminated  fatally  in  about  a  quarter  of  an  hour.  Previously'  to 
the  dyspnoea,  no  cough  had  been  noticed,  or  other  symptoms  referable 
to  the  chest. 

Aufoj)f^;/. — Body  considerably  emaciated  ;  left  lung  healthy,  with  the 
exception  of  slight  hypostatic  congestion;  right  lung  adherent  to  the 
diaphragm,  and  to  a  considerable  part  of  the  costal  i)leura,  by  fibrinous 
exudation;  this  lung  was  somewhat  compressed  and  non-crei)itant;  the 
upper  lobe  floated  in  water;  the  middle  and  lower  sank  and  could  not 
be  inflated,  or  but  slightly;  this  portion  of  the  lung  contained  a  few 
small  abscesses,  filled  with  purulent  matter,  each  holding  scarcely  more 
than  one  drop;  two  of  these  seemed  to  have  discharged  into  the  pleural 
cavit}',  as  the  air  passed  through  them  in  attempting  to  inflate,  l)ut 
possibly  they  may  have  been  opened  in  separating  the  adhesions  which 


ANATOI^IICAL    CnARACTERS.  511 

united  the  two  pleural  surfaces  at  this  point;  two  or  three  ounces  of 
thiid  wore  contained  in  tlie  pleural  cavity,  consisting,  in  addition  to 
serum,  of  fibrinous  tlocculi,  epithelial  cells  from  the  i)leura,  pus  cells, 
and  compound  granular  cells:  the  lower  portion  of  this  fluid,  on  stand- 
ing-, contained  so  much  i)us  that  it  presented  the  characteristic  gelatinous 
ai)pearance  on  the  addition  of  liquor  potassiu;  the  other  organs  generally 
were  normal  in  appearance,  but  the  liver  was  somewhat  congested,  and 
there  was  also  decided  hypernjraia  of  the  mucous  membrane  of  the  colon 
near  the  ileo-ccecal  valve,  and  in  the  descending  portion. 

In  cases  like  the  above,  the  pleuritis  is  obviously  due  either  to 
the  escape  of  pus  from  the  lung  into  the  pleural  cavity,  or  to  its 
near  approach  to  the  pleura.  In  the  former  case  the  inflamma-' 
tion  is  apt  to  be  general;  in  the  latter  circumscribed.  The  above 
cases  are  interesting,  as  sliowing  an  occasional  result  of  circum- 
scribed pneumonitis  in  the  infant,  namely,  hydrothorax  in  addition 
to  pleuritis. 

Sometimes,  especially  in  young  children,  the  cause  of  the  pleuritis 
is  apparently  general,  or  constitutional,  but  is  obscure.  Thus,  at 
the  autopsy  of  an  infant  who  died  at  the  age  of  about  one  month 
in  the  Infant's  Service  of  Charity  Hospital,  in  1867,  a  small  amount 
of  pus,  not  more  than  a  drachm,  was  found  in  one  pleural  cavity, 
and  less  than  this  quantity  in  the  other.  On  both  sides  there  was 
nearly  general  injection  of  both  the  visceral  and  costal  pleurae,  but 
without  exudation  of  serum  or  fibrin.  There  was  pus  also  at  the 
roots  of  the  lungs,  extending  somewhat  over  the  lungs  but  under 
the  pleura.  The  fact  of  a  double  pleurisy  appeared  to  indicate  a 
constitutional  cause,  but  there  was  no  apparent  cause  of  this  nature 
except  cachexia,  to  which  allusion  has  already  been  made,  as  predis- 
posing to  this  form  of  inflammation. 

Anatomical  Characters. — The  first  appreciable  structural 
change  which  occurs  in  pleuritis  is  engorgement  of  the  vessels 
lying  underneath  the  pleura.  Tliere  can  be  seen,  if  an  opportunity 
is  presented,  as  in  the  case  detailed  above,  a  network  of  engorged 
capillaries.  Immediately  exudation  commences  into  the  connec- 
tive tissue  surrounding  the  capillaries,  the  pleura  becomes  ojDaque, 
and  liquor  sanguinis  escapes  on  its  free  surface.  The  amount  of 
serum  and  fibrin  which  is  exuded  into  the  pleural  cavity  varies 
greatly  in  dift'erent  cases,  as  does  their  relative  projiortion. 

In  pleuritis  due  to  the  irritation  of  tubercles,  or  to  extension  of 
inflammation  from  an  inflamed  lung  to  the  pleura  wMch  covers  it, 
the  amount  of  serum  is  ordinarily  small,  and  occasionally  almost 
entirely  absent,  so  that  the  visceral  and  costal  surfaces  remain  in 
contact.     In  other  cases,  namely,  wlien  the  pleuritis  is  idiopathic. 


512  PLEURITIS. 

or  due  to  uraemia,  or  to  a  foreign  substance  in  the  pleural  cavity, 
the  amount  of  serous  eft'usion  is  considerable,  producing  more  or 
less  compression  of  the  lung.  The  most  frequent  exceptions  to 
these  general  statements  I  have  observed  in  the  pleurisy  of  tuber- 
culosis in  infants,  in  which  form  of  the  disease  the  lung  is  not 
infrequently  somewhat  compressed  by  the  liquid. 

Ordinarily  the  fibrin  forms  a  layer  over  the  inflamed  pleura,  at 
first  soft  and  readily  detached,  but  gradually  becoming  firmer,  and 
shreds  or  flocculi  of  fibrin,  becoming  separated,  float  in  the  exuded 
serum.  When  the  inflammation  has  continued  a  short  time, 
granulations  appear  on  the  inflamed  surface,  receiving  their  supply 
of  bloqd  from  the  sub-pleural  capillaries,  which  have  been  pro- 
longed. These  granulations,  when  the  serum  is  absorbed,  uniting 
with  those  on  the  opposite  side,  form  permanent  adhesions, 

Pleuritis,  except  when  due  to  a  local  cause  seated  beneath  the 
j^leura,  as  tubercle  or  pneumonitis,  extends  rapidly,  soon  becoming 
general. 

In  a  certain  proportion  of  cases  empyema  occurs.  The  propor- 
tion of  pleurisies  in  feeble  and  ill-conditioned  infants  which  are  or 
become  suppurative  is  very  large.  Hence  empyema,  as  I  have  often 
noticed,  is  not  infrequent  in  the  institutions  of  this  city  where  such 
infants  are  treated.  As,  in  recent  fatal  cases,  we  find  the  exuda- 
tion mainly  sero-fibrinous,  and  empyema  in  those  who  have  lived 
a  month  or  more,  it  has  seemed  to  me  that  the  suppuration  is 
probably  referable  to  -the  irritating  eftect  of  the  fibrin,  which, 
liquefying,  and  not  absorbed  on  account  of  the  general  feebleness, 
acts  as  an  irritant,  and  provokes  a  suppurative  inflammation. 

Pleuritis  has,  for  convenience  of  description,  been  divided  into 
three  stages:  the  first,  extending  from  the  commencement  of  the 
inflammation  to  the  time  when  there  is  an  appreciable  amount  of 
exudation;  the  second,  from  the  time  that  the  exudation  is  appre- 
ciable to  the  commencement  of  absorption;  the  third  stage  is  that 
of  absorption  or  convalescence.  Absorption  commences  when  the 
inflammation  abates,  and  the  rapidity  with  which  the  fluid  dis- 
appears varies  greatly  in  difierent  cases.  As  absorption  occurs, 
the  compressed  lung  gradually  expands  to  occupy  the  place  of  the 
fluid.  Sometimes  absorption  occurs  more  rapidly  than  the  expan- 
sion, so  that  there  is  depression  for  a  time  of  the  thorax  on  the 
aflected  side,  which  gradually  disappears.  The  serum  is  first 
absorbed,  and  then  the  fibrin,  undergoing  fatty  degeneration  and 
liquefaction,  is  also  absorbed.  Occasionally  portions  of  the  fibrin 
instead  of  being  absorbed  undergo  calcification,  after  which  tliere 


SYMPTOMS.  513 

is  no  fartlier  change.  Commonly,  as  the  serum  is  removed  the  two 
pleural  surfaces  become  permanently  adherent,  and  the  lobes  are 
likewise  united  to  each  other. 

In  rare  instances,  in  which  there  is  a  large  amount  of  serous 
exudation,  producing  complete  carnification  of  the  lung,  and 
absorption  is  slow,  inflation  never  occurs,  and  the  ribs  of  the 
affected  side  are  permanently  depressed.  Eespiration  henceforth 
is  performed  entirely  by  the  other  lung,  which  increases  somewhat 
in  volume  by  hypertrophy  of  the  air  cells.  The  compressed  lung 
remains  non-crepitant  and  firm,  and  its  color  somewhat  lighter 
than  the  natural  hue,  from  defective  supply  of  blood  and  granular 
change  in  its  anatomical  elements. 

In  empyema,  absorption  obviously  cannot  occur  unless  the 
quantity  of  pus  is  small.  Empj-ema,  therefore,  except  when  re- 
lieved by  paracentesis,  is  a  lingering  disease,  attended  by  many  of 
the  symptoms  of  tuberculosis.  Spontaneous  cure  occasionally 
occurs",  by  discharge  of  pus  into  a  bronchial  tube,  or  externally 
through  the  walls  of  the  chest.  I  have  witnessed  both  these 
modes  of  termination.  In  certain  instances,  pleuritis  on  the  left 
side  becomes  complicated  with  pericarditis,  and,  more  rarely,  pleu- 
ritis in  the  lower  jmrt  of  the  right  pleural  cavity,  with  perihepatitis, 
the  inflammation  extending  in  the  one  case  through  the  pericar- 
dium, in  the  other  through  the  diaphragm.  I  have  met  four  cases 
of  the  former  complication,  and  one  of  the  latter  in  infants. 

Symptoms. — Occasionally  pleuritis  is  latent.  This  may  be  its 
character,  both  in  the  primary  and  secondary  form,  latency  being 
more  frequent  in  infancy  than  in  childhood.  The  following  is  an 
example.  A  feeble  infant,  5  months  28  days  old,  died  suddenly 
at  the  l^ursery  and  Child's  Hospital,  December  29th,  1870.  The 
attention  of  the  resident  physician  had  not  been  called  to  it,  as  it 
was  not  supposed  to  be  sick,  although  its  general  condition  was 
bad,  and  the  attendant  nurse  who  had  charge  of  the  ward  denied 
that  there  was  any  symptom,  unless  possibly  an  occasional  slight 
cough  in  the  last  three  or  four  days.  Percussion  over  the  right 
side  of  the  chest  of  the  corpse  gave  a  flat  resonance,  and  the  rio-bt 
lung  was  found  at  the  autopsy  carnified  and  covered  with  a  loose 
fibrinous  layer,  in  places  three-fourths  of  an  inch  thick. 

As  circumscribed  pleurisy  is  for  the  most  part  a  secondary  dis- 
ease, the  symptoms  which  are  present  are  due  partly  to  it  and 
partly  to  the  primary  aflfection.  Obviously  the  symptoms  vary  in 
diflerent  cases,  according  to  the  presence  or  absence  of  other  dis- 
eases, the  age  and  robustness  of  the  patient,  and  the  extent  of  the 
83 


614  PLEURITIS. 

inflammation.  In  most  cases  the  commencement  of  plenritis  is  in- 
dicated by  increase  in  the  frequency  of  the  pulse  and  respiration, 
the  expiratory  moan,  and  sometimes  by  tenderness  on  percussion 
over  the  seat  of  the  inflammation.  There  is  a  short  cough,  dry  or 
hacking,  unless  bronchitis  coexists,  in  which  case  there  is  more  or 
less  expectoration;  at  the  same  time,  those  symptoms  are  present 
which  are  common  in  all  inflammatory  afiections,  such  as  anorexia, 
thirst,  and  increase  of  temperature.  The  symptoms  enumerated, 
though  commonly  so  severe  as  to  draw  attention  at  once  to  the 
chest,  are  in  other  cases  so  mild,  even  when  the  inflammation  is 
not  latent,  that  they  may  be  at  first  overlooked.  There  is,  indeed, 
every  gradation  between  severe  symptoms  and  latency. 

In  acute  general  pleuritis  the  symptoms  are  commonly  severe. 
The  pulse  rises  to  130  or  140  beats  per  minute,  and  in  young 
children  it  may  be  more  frequent ;  the  respiration  is  increased  in 
a  corresponding  degree ;  the  face  is  flushed  and  indicative  of  suf- 
fering; the  patient  is  restless,  complaining,  if  old  enough  to  speak, 
of  the  stitch-like  pain  in  the  chest,  which  is  most  intense  on  in- 
spiration and  in  coughing.  The  mean  temperature,  according  to 
the  observations  of  Mr.  Squire,  is  101°  Fahr. 

When  exudation  occurs  the  symptoms  abate  partially.  The 
pulse  and  respiration  are  less  frequent,  though  still  accelerated,  and 
the  latter  is  less  painful.  Convalescence  is  more  protracted  in 
pleuritis  than  in  pneumonitis.  Several  weeks  frequently  elapse 
before  the  liquid  is  fully  absorbed,  during  which  time  there  is  more 
or  less  acceleration  of  pulse.  The  appetite  and  strength  return 
gradually. 

In  suppurative  pleuritis  or  empyema,  the  symptoms  may  not 
dift'er  materially  at  first  from  those  in  the  ordinary  form  of  inflam- 
mation, but  absorption  does  not  occur,  or  there  is  but  a  slight  de- 
gree of  it,  limited  to  a  portion  of  the  liquor  puris.  The  pus  produces 
the  ordinary  eftects  of  purulent  collections  in  the  system,  namely, 
loss  of  appetite,  hectic  fever,  emaciation,  loss  of  strength.  No  im- 
provement occurs  except  by  discharge  of  pus,  when  restoration  to 
health  is  often  rapid.  In  fatal  cases  of  empyema  the  vital  powers 
gradually  yield,  the  pulse  becomes  more  frequent  and  feeble,  the 
face  and  limbs  pale  and  cool,  and  death  occurs  from  asthenia. 

Physical  Signs. — The  physical  signs  vary  according  to  the  ex- 
tent of  the  inflammation,  and  the  amount  of  exudation.  The  fric- 
tion sound  is  seldom  observed  in  the  infant,  and  it  is  less  frequently 
heard  in  the  child  than  in  the  adult. 

Percussion,  in  the  commencement  of  pleuritis,  before  there  is  any 


PnYSICAL    SIGNS.  515 

appreciable  exudation,  gives  a  negative  result.  If  dulness  is  ob- 
served, it  is  due  to  coexisting  disease,  commonly  pneumonitis  or 
tuberculosis.  In  tbose  cases  in  which  no  effusion  of  serum  occurs, 
or  in  dry  pleurisy,  as  it  is  termed,  percussion  at  all  periods  of  tlie 
disease  gives  only  negative  information,  impaired  resonance  if 
present  being  due  to  the  pulmonary  disease,  pneumonitis  or  tuber- 
cles, to  which  this  form  of  pleurisy  is  commonly  due.  In  a  large 
proportion  of  circumscribed  pleurisies  the  percussion  sound  is  not 
materially  affected. 

If  there  is  serous  effusion,  and  this  occurs  in  most  pleuritic 
attacks  which  are  not  dependent  on  pulmonary  disease,  and  some 
in  which  there  is  this  dependence,  percussion  over  the  liquid 
elicits  a  flat  sound,  while  the  resonance  above  the  level  of  the 
liquid  is  good,  and  occasionally  even  tympanitic.  Flatness  on  per- 
cussion distinguishes  pleuritic  effusion  from  simple  pneumonitis, 
since  in  pneumonitis  percussion  produces  a  dull,  but  not  fiat,  sound. 
In  young  children  in  whom  pneumonitis  is  catarrhal  and  limited 
to  a  part  of  a  lobe,  the  difference  is  very  marked.  Change  in  the 
height  of  the  flatness,  according  to  the  position  of  the  patient,  is 
observed  in  infancy  and  childhood,  not  less  than  in  adult  life. 
•  "When  the  second  stage  commences,  and  the  pleural  cavity  con- 
tains more  or  less  liquid,  the  respiratory  sound  often  disappears 
from  the  part  of  the  chest  which  is  occupied  by  the  liquid  in  chil- 
dren over  the  age  of  five  or  six  years,  but  in  a  large  proportion  of 
cases  in  the  first  years  of  childhood,  and  usually  in  infancy,  in 
which  period  the  pleural  cavity  is  small,  respiration  is  heard  with 
the  ear  applied  over  the  liquid.  It  is  transmitted  from  a  distance. 
Its  character  is  bronchial,  broncho-vesicular,  or  even  sometimes 
vesicular.  It  appears  in  certain  cases,  especially  when  vesicular, 
to  be  transmitted  from  the  opposite  side  of  the  chest. 

It  varies  in  its  intensity,  according  to  the  amount  of  the  licjuid 
and  the  strength  and  rapidity  of  the  respiration.  It  sometimes, 
according  to  Rilliet  and  Barthez,  partakes  of  the  cavernous  respi- 
ratory sound,  so  that,  in  the  first  case  in  which  they  observed  this 
modification,  their  diagnosis  was  erroneous.  There  was  complete 
restoration  to  health,  with  absorption  of  the  fluid,  although  they 
had  diagnosticated  a  cavity. 

If  there  is  a  large  amount  of  fluid  and  the  lung  is  compressed 
at  the  top  of  the  pleural  cavity,  bronchial  respiration  may  be  heard 
above  the  level  of  the  fluid,  in  the  infra-clavicular  region.  In  the 
adult  this  is  a  common  physical  sign.  -<^gophony  is  occasionally 
observed  in  acute  cases,  in  which  there  is  a  rapid  and  large  eflusion. 


516  PLEURITIS. 

It  is  heard  in  the  infra-  and  inter-scapular  spaces.  Its  duration  is 
commonly  brief,  disappearing  in  three  or  four  days  or  even  in  less 
time.  Bulging  of  the  intercostal  spaces  and  distension  of  the 
thoracic  walls  from  the  fluid  are  less  frequent  in  young  children, 
and  especially  infants,  than  in  adults.  In  the  infant,  so  readily  are 
the  lungs  compressed,  complete  carnification  is  apt  to  occur,  before 
the  shape  of  the  chest  is  materially  altered.  On  account  of  these 
peculiarities  as  regards  the  physical  signs  and  the  mechanical  effect 
of  a  liquid  in  the  pleural  cavity  of  a  young  child,  physicians  whose 
knowledge  of  pleuritic  effusions  is  derived  chiefly  from  the  exami- 
nation of  adult  cases  are  apt  to  err  in  diagnosis.  Thus,  in  1870  a 
carnified  lung,  covered  with  a  thick  pyogenic  membrane  from 
which  granulations  had  arisen,  was  presented  by  myself  to  the 
IS^ew  York  Pathological  Society,  with  the  following  history  of  the 
case.  W.,  twelve  months  old  at  the  time  of  death,  was  taken  sick 
at  the  age  of  six  months,  with  fever,  and  a  cough,  which  was  slight 
and  not  frequent.  At  about  eight  months  he  first  came  under  ob- 
servation. The  infant  was  then  small  for  its  age,  pallid  and  thin. 
The  two  sides  of  the  chest  measured  the  same,  and  on  both  sides 
the  intercostal  spaces  were  somewhat  depressed,  but  percussion 
over  the  right  side  produced  a  flat  sound,  showing  that  the  air  was 
wholly  excluded  from  the  right  lung.  The  respiration  upon  the 
affected  side  was  bronchial  and  distinct.  Two  well-known  physi- 
cians of  this  city,  thorough  in  their  examinations,  and  usually 
accurate  in  diagnosis,  examined  this  case  in  reference  to  the  pro- 
priety of  thoracentesis,  and  both  expressed  a  decided  opinion  that 
the  pathological  state  was  not  a  pleuritis,  but  either  collapse  or 
interstitial  pneumonitis,  one  of  them  observing,  as  he  thought,  in 
addition  to  the  physical  signs  already  stated,  bronchophony.  The 
febrile  movement  was  moderate,  and  no  decided  hectic  was  observed. 
Death  occurred  from  exhaustion.  At  the  autopsy  about  half  a 
pint  of  thick  pus  w^as  found  in  the  right  pleural  cavity,  producing 
complete  carnification  of  the  lung.  The  pus,  which,  considering 
the  stunted  growth  of  the  child  and  small  size  of  the  pleural  cavity, 
was  considerable,  had  evidently  lost  part  of  the  liquor  puris  by  ab- 
sorption. 

The  following  case,  which  shows  how  deceptive  the  physical 
signs  may  be  in  young  children  in  cases  of  suppurative  pleuritis, 
will  repay  perusal,  since  the  life  of  the  patient  depends  in  great 
part  on  a  correct  understanding  of  his  condition,  so  that  appropriate 
measures  will  be  employed: — 


DIAGNOSIS.  517 

Case. — IT — ,  boy  four  years  four  months  old,  was  taken  with  scarlet 
fever  in  the  latter  part  of  May,  1868.  It  was  severe,  and  was  attended 
witli  inflammation  of  the  "lands  and  connective  tissue  of  the  neck,  with 
suppui'ation  on  both  sides.  Purulent  discharges  from  the  al)scesse8 
continued  through  the  month  of  June.  The  patient  was  gradually  con- 
valescing, when,  about  July  4tli,  pleuritis  commenced  on  the  left  side, 
attended  by  the  ordinary  symptoms  of  acute  forms  of  this  inflammation. 
A  few  days  subsecpiently,  the  pleural  cavity  was  ascertained  by  physical 
examination  to  be  about  half  full  of  liquid. 

Towards  the  close  of  July,  anasarca  commenced  about  the  ankles  and 
gradually  extended  upwards.  It  was  limited  to  the  lower  extremities, 
and  to  the  abdominal  walls,  and  by  the  middle  of  August  became 
excessive.  The  thoracic  walls  and  the  upper  extremities  were  somewhat 
emaciated,  and  the  face  was  pallid  and  anxious. 

On  the  7th  of  August,  a  careful  examination  of  the  chest  was  made 
in  reference  to  the  propriety  of  thoracentesis.  The  intercostal  spaces 
on  tlie  left  side  were  not  prominent,  but  rather  depressed.  Percussion 
over  the  lower  third  of  the  left  pleural  cavity  elicited  a  flat  sound,  while 
above  this  the  resonance  was  tympanitic.  On  account  of  the  great  rest- 
lessness of  the  patient,  no  useful  information  was  derived  from  change 
of  position.  On  auscultation  distinct  bronchial  respiration  was  heard 
over  nearly  or  quite  the  entire  left  side  of  the  chest.  The  apex  beat  of 
tlie  heart  was  on  the  right  of  the  sternum.  It  was  my  opinion,  as  well 
as  that  of  two  other  physicians,  that  the  liquid  was  in  process  of  absorp- 
tion, and  that  the  quantity  present  was  not  large.  Thoracentesis  did 
not,  therefore,  seem  a  proper  measure. 

The  anasarca  still  limited  to  the  lower  extremities,  and  the  abdominal 
walls  continued  to  increase,  and  on  the  25th  of  August,  so  great  was  the 
distension,  that  the  skin  broke  in  one  or  two  places  above  the  ankles. 
The  mind  remained  clear,  and  the  appetite  was  prett3'  good.  Death 
occurred  August  21th. 

Secdo  Cadaver. — Head  not  examined  ;  abdominal  and  right  pleural 
cavities  contained  no  eft'usion,  and  were  in  their  normal  state,  except 
that  the  latter  cavity  was  somewhat  encroached  upon  by  the  heart  and 
mediastinum;  a  great  amount  of  oedema  in  the  lower  extremities  and  in 
the  abdominal  walls;  abdominal  walls  towards  the  spine  about  three 
inches  tliick,  in  consequence  of  oedema;  right  lung  of  good  size,  and  pre- 
senting the  ordinary  appearance  except  a  greater  amount  than  usual  of 
hypostatic  congestion;  about  three  pints  of  pus  (laudable)  in  the  left 
pleural  cavity;  left  lung  completely  carnified  and  lying  against  the 
vertebral  column,  its  size  about  that  of  an  orange,  and  its  surface 
covered  with  a  dense  layer  of  fibrin ;  heart  displaced,  as  alread}'  stated, 
to  the  right,  and  a  little  downward,  so  as  to  compress  and  partially 
obstruct  the  circulation  in  the  ascending  vena  cava;  this  vessel  con- 
tained a  continuous,  firm  and  yellow  fibrinous  clot,  nearly  filling  its 
calibre;  the  femoral  vein,  examined  on  one  side,  was  found  to  contain 
soft  and  dark  clots.  Compression  of  the  cava  opposite  the  heart  and 
the  formation  of  clots  had  evidently  given  rise  to  the  anasarca. 

Diagnosis. — This  is  in  certain  cases  readily  made,  but  in  others, 
as  we  have  seen,  is  attended  with  difficulty.  It  is  more  difficult 
in  those  under  than  over  four  or  five  years.  Partial  or  circum- 
scribed pleuritis,  attended  by  little  or  no  serous  exudation,  is  more 


518  PLEUKITIS. 

apt  to  be  overlooked  than  other  forms  of  the  inflammation,  but,  as 
it  is  ordinarily  due  to  graver  disease  of  the  lungs,  its  detection 
is  not  very  important.  The  points  involved  in  its  diagnosis  are 
acceleration  of  pulse  and  respiration,  increase  of  temperature, 
expiratory  moan,  friction  sound,  and  tenderness  on  percussion. 

The  diagnosis  of  acute  general  pleuritis  in  its  commencement, 
before  the  stage  of  effusion,  is  attended  with  some  difficulty.  It  is 
most  likely  to  be  mistaken  for  ^pneumonitis,  since  the  prominent 
symptoms  in  the  commencement  of  the  two  diseases  are  similar. 
There  is,  however,  in  pleuritis  ordinarily  greater  acceleration  of 
pulse  and  respiration,  greater  elevation  of  temperature,  greater 
suffering,  as  indicated  by  the  features,  and  a  more  decided  expira- 
tory moan.  It  will  aid  in  the  differential  diagnosis,  in  children 
under  the  age  of  five  years,  to  recollect  that  acute  pneumonitis  is 
in  most  instances  preceded  by  bronchitis,  which  is  not  the  case 
with  acute  pleuritis,  except  as  a  coincidence. 

Pleuritis  with  effusion  could  only  be  mistaken  for  pneumonitis 
or  hydrothorax.  But  the  loss  of  resonance  on  percussion  in  cases 
of  pleuritic  effusion  is  much  greater  than  when  the  lung  is  solidified 
from  pneumonitis.  The  physical  signs,  which  are  involved  in  the 
differential  diagnosis  of  these  diseases  in  the  adult,  are  important, 
also,  for  diagnosis  in  children,  though,  as  we  have  seen,  they  are 
less  constant  and  less  reliable  in  young  children  than  in  adults. 
In  children  over  the  age  of  five  years  they  are  pretty  uniformly 
present.  The  signs  alluded  to  are  bulging  of  the  intercostal  spaces, 
expansion  and  subsequently  retraction  of  the  chest,  evidence  of 
change  in  the  height  of  the  fluid,  by  change  in  the  position  of  the 
body,  no  bronchophony  and  fremitus  as  in  pneumonitis,  etc.  Hy- 
drothorax in  the  child  commonly  results  from  one  of  the  eruptive 
fevers,  especially  scarlatina,  and  its  immediate  cause  is  nephritic 
congestion  or  inflammation,  or  heart  disease.  Rarely  it  is  due  to 
obstruction  in  the  pulmonary  circulation,  in  consequence  of  enlarged 
bronchial  glands.  It  is  not,  therefore,  preceded  nor  accompanied 
by  symptoms  of  inflammation  referable  to  the  chest,  as  in  cases  of 
pleuritic  etiusion. 

Empyema  may  be  diagnosticated  from  the  fact  that  there  is 
little  or  no  diminution  in  the  amount  of  liquid  after  several  weeks 
have  elapsed,  and  from  the  febrile  movement,  loss  of  appetite,  flesh, 
and  strength,  which  attend  all  large  purulent  collections. 

Prognosis. — Primary  pleuritis,  occurring  in  patients  previously 
healthy,  commonly  ends  favorably ;  but  it  is  a  serious  disease  if 
the  general  health  has  been  much  impaired.     The  prognosis  is 


TREATMENT.  519 

more  favorable  if,  as   is  commonly  the  case  with  this  form  of 
pleurisy,  the  patient  is  over  the  age  of  three  or  four  years. 

Secondary  pleuritis  is,  on  the  other  hand,  a  grave  affection,  but 
the  prognosis  depends  greatly  on  the  character  of  the  primary  dis- 
ease, and  also  on  the  age.  Pleurisy  resulting  from  and  coexisting 
with  pneumonitis  commonly  ends  favorably  even  in  quite  young 
patients.  Pleuritis  arising  from  scarlet  fever  is  apt  to  be  suppura- 
tive, and  is,  therefore,  a  serious  complication  or  sequel,  but  a 
considerable  proportion  affected  with  it  recover  under  judicious 
treatment.  The  prognosis  in  tubercular  pleuritis  and  pleuritis 
occurring  from  the  escape  of  pus  into  the  pleural  cavity  is  obviously 
unfavorable. 

Tubercular  pleuritis  may  be  temporarily  relieved,  but  it  is  apt 
to  return.  Suppurative  pleuritis,  or  empyema,  is  also  an  unfavora- 
ble form  of  inflammation,  characterized  by  the  chronicity  and 
many  of  the  symptoms  of  tuberculosis.  It  is  in  time  fatal  unless 
the  pus  is  evacuated.  On  the  escape  of  the  pus,  whether  spontane- 
ously or  by  thoracentesis,  there  is  usually  progressive  and  complete 
restoration  to  health.  In  case  the  pus  is  evacuated,  the  prognosis 
is  better  in  children  than  in  adults. 

Treatment.^ — ^The  indications  of  treatment  are,  in  the  commence- 
ment of  the  inflammation,  to  diminish  its  intensity,  and  relieve 
pain ;  at  a  later  period,  to  promote  absorption  and  sustain  the  vital 
powers. 

Pleuritis  is  one  of  the  few  inflammations  in  early  life  in  which 
the  abstraction  of  blood  may  be  proper.  It  may  be  stated  as  a 
rule,  that  loss  of  blood  is  not  onl}^  not  required,  but  is  an  injudi- 
cious measure  in  all  secondary  pleurisies,  and  in  the  primary  form 
after  exudation  into  the  pleural  cavity  has  occurred.  It  is  a  useful 
measure  at  the  commencement  of  acute  primary  pleuritis  occurring 
in  a  robust  state  of  system.  One  or  two  leeches  should  be  applied 
directly  over  the  seat  of  the  inflammation,  and  bleeding  may  be 
encouraged  for  two  or  three  hours  subsequently  by  the  application 
of  cloths  wrung  out  of  warm  water.  Unfortunately  the  physician 
is,  in  many  cases,  not  called  at  this  early  period ;  or,  if  called,  he 
fails  to  make  the  dias^nosis  till  there  are  evidences  of  exudation. 

After  bleeding  has  ceased,  or  in  subacute  and  secondary  pleurisies 
without  the  employment  of  leeches,  rubefacient  applications  should 
be  made  over  the  affected  side  of  the  chest,  followed  by  a  poultice, 
or  flannel  wrung  out  of  warm  water  and  covered  with  oil-silk. 
Moderate  counter-irritation  diminishes  the  pain,  but  vesication  at 
this  early  period  is  injurious.     A  blister  applied  so  near  the  seat  of 


520  PLEURITIS. 

the  inflammation  may  increase  the  aiflux  of  blood  towards  it,  and 
aggravate  the  disease. 

Robust  patients  over  the  age  of  three  or  four  years  are  benefited 
by  the  use  of  cardiac  sedatives  in  the  commencement  of  acute 
pleuritis.  The  tincture  of  aconite  or  of  veratrum  viride  may  be 
given,  but  its  effects  shoukl  be  carefully  watched,  and  it  should  be 
discontinued  when  the  pulse  is  reduced  to  near  the  natural  fre- 
quency, or  when  sufficient  exudation  has  occurred  to  produce  the 
ordinary  physical  signs  of  liquid  in  the  chest.  They  should  not 
be  given  in  secondary  pleuritis. 

Opiates  are  required,  as  in  other  serous  inflammations,  accord- 
ing to  the  pain.  Dover's  powder,  in  doses  of  one  to  three  grains, 
according  to  the  age,  may  be  given  every  three  hours,  or  less  fre- 
quently if  the  patient  is  inclined  to  sleep. 

Such  is  the  treatment  required  in  the  first  stage  of.  acute 
primary  pleuritis,  or  that  preceding  the  effusion.  Secondary 
pleuritis  requires  fewer  and  less  depressing  measures.  The  appro- 
priate treatment,  in  a  large  proportion  of  the  cases  of  this  form 
of  the  disease,  consists  in  the  use  of  an  opiate,  with  rubefacient 
and  emollient  applications  to  the  chest.  Abstraction  of  blood, 
and  powerful  cardiac  sedatives,  as  aconite  and  veratrum  viride, 
are  dangerous  remedies  in  secondary  pleurisies,  and  are  almost 
never  used. 

Pleurisies  dependent  on  pulmonary  disease,  which  are  circum- 
scribed and  attended  with  little  serous  eiiusion,  require  no  other 
therapeutic  measures  than  those  already  mentioned.  The  judi- 
cious use  of  opiates,  and  rubefacient  and  emollient  applications, 
suffice  for  their  treatment. 

In  the  treatment  of  other  forms  of  pleurisy,  which  are  attended 
by  more  or  less  effusion  of  liquid  into  the  pleural  cavity,  measures 
designed  to  remove  this  liquid  are  required  when  the  inflammation 
has  abated,  and  antiphlogistics  are  no  longer  appropriate. 

Liquids  in  the  great  cavities  are  best  eliminated  by  hydragogue 
cathartics  and  by  diuretics.  For  children,  however,  already  weak- 
ened by  pleuritic  inflammation,  cathartics  are  usually  too  depress- 
ing unless  for  one  or  two  days.  Now  and  then  a  robust  patient, 
over  the  age  of  five  or  six  years,  with  pleuritic  eff'usion,  may  be 
benefited  by  an  occasional  purgative  dose  of  bitrate  of  potassa,  or 
by  from  one-twelfth  to  one-sixth  of  a  grain  of  podophyllin.  But 
such  cases  are  exceptional.  In  a  majority  of  children  the  loss  of 
strength  resulting  from  cathartics  more  than  counterbalances  the 
good  result  from  the  liquid  evacuations  which  they  produce. 


TREATMENT.  521 

Diuretics,  on  the  other  hand,  arc  efficient  remedies,  and  upon 
them  our  chief  reliance  must  be  placed. 

Tlie  diuretic  from  which  I  have  seen  better  effects  than  froni 
any  other  is  iodide  of  potassium,  but  it  should  be  given  in  large 
doses.  In  the  adult  I  have  observed  rapid  absorption  of  the 
liquid  by  the  administration  of  from  one  to  two  drachms  daily  of 
this  agent,  given  in  doses  of  ten  grains,  and  a  child  can  take  a 
proportionate  dose.  Two  to  five  grains,  according  to  the  age,  may 
be  given  every  three  hours.  At  the  same  time  it  is  advisable  to 
restrict  the  drinks. 

At  this  stage  of  the  disease  counter-irritation  is  appropriate, 
either  by  rubefacients  or  vesicants.  The  preferable  mode  of 
blistering  the  child  is,  in  my  opinion,  by  cantharidal  collodion 
applied  as  recommended  in  the  treatment  of  pneumonitis. 

In  secondary  pleuritis  the  diet  should  be  nutritious,  consisting 
largely  of  animal  broths,  through  the  whole  period  of  the  disease. 

In  primary  pleuritis  nutritious  diet  should  be  allowed  after  exu- 
dation has  occurred.  In  some  cases,  more  frequently  in  secondary 
than  primary  pleuritis,  stimulants  are  required.  In  protracted 
pleurisy,  or  pleurisy  occurring  in  a  debilitated  patient,  tonics,  both 
vegetable  and  chalybeate,  are  often  serviceable,  sustaining  the 
strength  while  the  process  of  absorption  is  going  on. 

Occasionally  the  measures  which  have  been  recommended  above 
to  promote  absorption  of  the  liquid  in  the  pleural  cavity  do  not 
have  the  effect  which  is  desired.  If  there  is  no  sensible  diminu- 
tion in  its  amount,  and  if  the  general  health  of  the  patient  begins 
to  fail,  the  performance  of  thoracentesis  should  be  considered.  "We 
may  accomplish  by  surgery  what  we  fail  to  effect  by  therapeutic 
means.  The  following  are  the  remarks  by  Prof.  Flint,  on  this 
subject.  They  apply  to  thoracentesis  in  children  as  well  as  adults. 
(Flint's  Practice  of  Medicine^  2d  ed.,p.  155.) 

"Heretofore  this  operation  was  performed  only  as  a  dernier  resort^ 
under  circumstances  when  little  was  to  be  expected  from  any 
measure.  It  was  deferred  as  long  as  possible,  sometimes  on  account 
of  doubt  as  to  the  diagnosis,  and  because  the  perforation  and 
introduction  of  air  were  supposed  to  involve  danger  of  an  increase 
of  the  inflammation.  A  considerable  opening  was  necessary  in 
order  to  give  free  exit  to  the  liquid,  and  it  was  not  easy  to  prevent 
the  air  from  entering  the  pleural  cavity.  Objection  to  the  opera- 
tion on  the  score  of  diagnosis  is  now  removed  by  our  present 
knowledge  of  physical  signs.  Moreover,  the  operation  has  been 
divested  of  all  severity,  and  the  liability  to  the  introduction  of  air 


522  PLEURITIS. 

has  been  provided  against  "by  the  application  of  the  suction  pump, 
first  suggested  by  Dr.  Morill  Wyman,  in  1850,  and  since  employed 
in  a  large  number  of  cases  by  Dr.  Bowditch.  The  introduction  of 
air  is  not  attended  by  the  injurious  eftects  formerly  apprehended, 
but  it  is  objectionable  because  the  presence  of  air  is  an  obstacle  to 
the  full  expansion  of  the  lung  after  the  liquid  is  removed.  Its 
introduction  is  prevented  by  the  use  of  the  pump  in  withdrawing 
the  liquid.  The  operation  is  rendered  trivial,  because  with  the 
suction  force  of  the  pump  a  small  exploring  trocar  suffices  to  make 
the  puncture,  which  causes  very  little  pain,  and  closes  directly  the 
canula  is  removed." 

Dr.  Bowditch  had  performed  the  operation  one  hundred  and 
fifty  times  on  seventy-five  individuals  prior  to  1863,  in  the  manner 
described  above,  and  in  twenty-nine  of  the  patients  recovery  was 
apparently 'due  to  it.  Prof.  Flint  has  several  times  successfully 
performed  the  operation,  using  a  small  trocar  and  canula  made  to 
screw  on  the  flexible  suction  tube  of  Davidson's  syringe. 

M.  Gruersant  describes  his  mode  of  performing  thoracentesis,  in 
the  Ball.  Gener.  de  Therap.,  Oct.  15,1866.  He  generally  "plunges 
in  the  instrument  above  the  superior  border  of  the  tenth  rib  on 
the  left  side,  and  the  eighth  rib  on  the  right,  and  at  the  junction 
of  the  posterior  one-third  with  the  anterior  two-thirds  of  the  inter- 
costal space.  He  employs  a  trocar  about  two  lines  in  diameter, 
and  nearly  two  inches  in  length,  curved  like  a  tracheotomy  canula 
and  furnished  with  a  flap  of  membrane  over  its  external  orifice. 
The  child  is  placed  upon  its  back,  and  firmly  held,  while  the 
operator  with  his  left  hand  draws_  upon  the  skin,  and  with  his 
right  inserts  the  trocar,  with  its  concavity  looking  downwards  so 
as  to  avoid  injuring  the  lung.  The  membrane  at  the  external 
orifice  of  the  canula,  being  previously  moistened,  excludes  the  en- 
trance of  air.  On  withdrawing  the  instrument,  the  skin  passes 
over  the  wound,  and  the  parts  unite  by  first  intention,  provided 
that  the  liquid  is  sero-fibrinous." 

The  following  are  my  experience  and  views  in  reference  to  this 
operation.  Thoracentesis  is  rarely  required  in  the  child  except  for 
eiiipyema,  and  it  should  not  as  a  rule  be  performed  in  less  time 
than  eight  weeks  after  the  commencement  of  the  inflammation,  so 
as  to  allow  as  much  as  possible  of  the  liquid  to  be  absorbed.  If 
the  health  of  the  patient  is  but  little  impaired,  it  is  proper  to 
wait  longer,  for,  if  the  efiVision  is  largely  sero-fibrinous,  and  the 
amount  of  pus  small,  recovery  is  possible  by  absorption,  for  a  small 
amount  of  pus  may  be  absorbed,  the  pus  cells  undergoing  fatty 


TREATMENT.  523 

degeneration  and  liquefaction.  The  operation  can  be  best  per- 
formed with  the  patient  etherized,  the  point  selected  being  a  little 
below  the  lower  angle  of  the  scapula.  The  operation  is  no  more 
difficult  than  the  opening  of  any  deep  abscess,  and  it  is  not 
dangerous  to  the  patient.  The  skin  being  drawn  up  a  little,  so 
that  after  the  operation  it  will  close  the  ojtening  like  a  valve,  an 
incision  should  be  made  through  the  integument,  and  then  a 
medium-size  trocar  pushed  through  the  walls  of  the  chest  into  the 
cavity  at  the  upper  border  of  the  rib.  A  trocar  of  medium  size  is 
preferable  to  one  that  is  smaller,  as  the  pus  is  often  thick  and  would 
flow  with  difficulty.  Or,  without  the  trocar,  the  operation  may 
be  performed  by  the  bistoury  alone.  The  admission  of  a  moderate 
amount  of  air  into  the  pleural  cavity  in  tapping  for  empyema  does 
no  harm,  except  so  far  as  it  prevents  inflation,  since  the  pleural 
surface  with  which  it  comes  in  contact  is  already  a  pyogenic 
membrane.  "When  the  pus  ceases  to  flow,  the  curved  end  of  a 
pocket  male  catheter  may  be  introduced,  and  with  the  India- 
rubber  syringe  attached  more  pus  can  be  removecL  I  prefer,  how- 
ever, to  make  the  aperture  sufficiently  large,  enlarging  it  a  little 
if  necessary  with  a  bistoury,  that  it  may  remain  as  a  fistulous  open- 
ing from  which  pus  continues  to  flow.  The  skin  acting  as  a  valve 
prevents  the  admission  of  air  after  the  canula  is  withdrawn.  If 
the  discharge  ceases  after  a  day  or  two,  the  small  quantity  of  pus 
remaining  will  commonly  be  absorbed.  The  injection  daily  into 
the  pleural  cavity,  as  long  as  the  aperture  remains,  of  a  weak 
solution  of  carbolic  acid,  of  the  temperature  of  the  blood,  expedites 
recovery,  but  without  this  there  is  a  gradual,  though  sometimes 
slow,  convalescence. 

Since  the  publication  of  the  first  edition  of  this  book,  thoracen- 
tesis has  been  performed  in  four  children  in  my  own  practice,  and 
in  one  at  the  Out-door  Department  at  Bellevue.  In  four  the 
apertures  was  left  open,  being  covered  with  oakum,  and  allowed 
to  drain,  but  in  three  of  these  pus  soon  ceased  to  flow.  The  five 
children  operated  on  recovered  gradually,  though  four  of  them 
were  in  a  reduced  state  which  involved  immediate  danger.  In 
about  the  same  period  death  occurred  in  nearly  an  equal  number, 
in  whom  the  operation  was  not  performed,  in  consequence  of 
uncertain  diagnosis  or  for  other  reasons.  The  one  of  those  operated 
on,  in  whom  thoracentesis  was  longest  deferred,  was  taken  with 
pleuritis  of  the  right  side  in  April,  1871,  and  the  pus  was 
evacuated  by  the  knife  in  September  following,  the  trocar,  which 


524  PLEURITIS. 

was  introduced  immediately  afterwards,  being  of  little  use,  as  the 
pus  escaped  by  its  side.  Although  the  general  health  of  the  child, 
which  remained  for  a  time  precarious,  is  fully  restored,  there  are 
evidences  of  incomplete  inflation  of  the  lung.  These  few  cases,  if 
they  correspond,  as  I  believe  they  do,  with  more  ample  statistics, 
show  the  urgent  need  of  thoracentesis  in  the  empyema  of  children, 
and  the  probability  of  a  favorable  result,  even  when  it  is  performed 
under  discouraging  circumstances. 

If  the  liquid  removed  by  the  operation  prove  to  be  sero-fibrinous, 
it  is  very  important  that  no  air  enter  the  pleural  cavity,  as  it  would 
be  likely  to  produce  a  suppurative  inflammation.  Therefore,  the 
puncture  of  the  walls  of  the  chest  should  always  be  made  with 
the  trocar  in  those  cases  in  which  there  is  doubt  as  to  the  nature 
of  the  liquid,  since  the  entrance  of  air  can  be  most  readily  pre- 
vented when  this  instrument  is  employed.  Tn  certain  cases,  in 
which  absorption  is  slow,  and  empyema  is  suspected  from  the 
symptoms,  it  is  proper  to  ascertain  the  nature  of  the  liquid  by  the 
exploring  needle  before  instituting  any  operative  procedure. 


SECTIO]^  III. 

DISEASES  OF  THE  DIGESTIVE  APPARATUS. 


CnATTER    I. 

SIMPLE  STOMATITIS  ;   ULCEROUS  STOMATITIS  ;   FOLLICULAR 

STOMATITIS. 

Diseases  of  the  digestive  system  in  infancy  and  childhood  are 
of  frequent  occurrence.  They  are  for  the  most  part  readily  recog- 
nized, and  are  more  easily  and  quickly  controlled  by  therapeutic 
agents,  if  rightly  applied,  than  are  the  diseases  of  any  other  system. 
If  misunderstood  and  improperly  treated,  they  may,  even  when 
mild  and  very  manageable  in  their  commencement,  become  chronic 
and  obstinate,  or  even  fatal,  or  they  may  lead  to  other  and  more 
dangerous  diseases.  It  is  necessary,  then,  that  the  physician  should 
understand  thoroughly  the  pathology  as  well  as  therapeutics  of 
the  digestive  system,  that  he  may  make  timely  and  correct  use  of 
the  required  remedies. 

The  diseases  of  the  buccal  cavity  in  early  life  are  for  the  most 
part  inflammatory.     The  mildest  is  that  known  as 

Simple  or  Erythematic  Stomatitis. 

This  form  of  inflammation  occurs  usually  before  the  completion 
of  first  dentition,  and  it  is  most  frequent  under  the  age  of  one 
year.  Giving  rise  in  itself  to  no  severe  symptoms,  and  often  being 
connected  with  other  grave  and  dangerous  aflfections,  it  is,  doubt- 
less, in  many  cases  overlooked.  It  is  sometimes  confined  to  a  por- 
tion of  the  buccal  surface,  or  is  more  intense  in  one  part  than  in 
another.  In  other  cases  the  stomatitis  is  uniform,  or  nearly  so, 
aflecting  the  entire  cavity  of  the  mouth. 

Causes. — The  common  cause  of  simple  stomatitis  in  infants  is 
the  same  as  that  of  most  cases  of  gastro-intestinal  inflammation 
at  that  age.  This  is  the  use  of  indigestible  and  therefore  irritating 
food,  uncleanliness,  personal  and  domiciliary;    in  fine,  all  those 


526  SIMPLE    OR    ERYTHEMATIC    STOMATITIS. 

agencies  which  impair  the  general  health,  and  enfeeble  the  diges- 
tive organs.  Therefore,  stomatitis,  like  entero-colitis,  is  more 
common  in  the  city  than  in  the  country,  and  among  the  city  poor 
than  those  in  the  better  walks  of  life.  Infants  deprived  of  the 
mother's  milk  and  given  a  diet  which,  with  all  care  of  preparation, 
is  a  poor  substitute  for  the  natural  aliment,  are  very  liable  to  this 
disease.  Beaumont  ascertained  from  his  experiments  on  St.  Martin 
that  irritative  changes  produced  in  the  stomach  by  indigestible 
substances  were  soon  followed  by  similar  changes  in  the  buccal 
mucous  membrane.  Since  in  young  infants  any  kind  of  artificial 
food  is  less  digestible  than  the  breast  milk,  it  is  evident  why  those 
who  are  prematurely  weaned  or  are  carelessly  fed  are  so  liable  to 
stomatitis.  This  inflammation  is  also  sometimes  due  to  irritating 
substances  taken  in  the  mouth,  as  drinks  habitually  too  hot  or  too 
cold.  Stomatitis  is  also  present  in  measles  and  scarlet  fever.  It 
then  corresponds  with  the  cutaneous  eruption,  and  disappears 
when  that  subsides. 

Another  cause  is  dentition.  The  gum  over  the  advancing  tooth 
first  becomes  inflamed,  and,  other  causes  perhaps  conspiring,  the 
inflammation  extends  over  more  or  less  of  the  buccal  surface. 
When  due  to  dentition  the  stomatitis  is  more  apt  to  be  partial 
than  when  it  arises  from  a  constitutional  cause.  Mercury,  in 
whatever  form  introduced  into  the  system,  excreted  from  the 
salivary  glands,  and  flowing  over  the  buccal  surface,  is  an  occa- 
sional though  now-a-days  rare  cause. 

Symptoms,  Appearances. — Stomatitis,  like  other  mucous  inflam- 
mations, is  characterized  by  increased  redness  and  more  or  less 
thickening  of  the  inflamed  buccal  membrane,  by  rapid  proliferation 
and  exfoliation  of  epithelial  cells,  and  by  an  increased  functional 
activity  of  the  muciparous  follicles.  The  heat  of  the  mouth  is 
sometimes  augmented  in  an  appreciable  degree.  The  gums  in 
severe  cases  are  swollen  and  spongy,  and  bleed  easily  if  rubbed  or 
pressed.  The  tongue  is  usually  covered  with  a  light  fur,  and  the 
salivary  secretion  is  augmented  to  such  an  extent  sometimes  as  to 
dribble  from  the  corners  of  the  mouth.  Often  there  is  little  sufter- 
ing,  but  in  other  cases  the  child  is  fretful,  experiences  pain  from 
the  contact  of  solid  food,  and  if  nursing  may  even  wean  itself, 
from  dread  of  pressure  of  the  nipple. 

Simple  stomatitis  is  not  difficult  of  detection,  provided  atten- 
tion is  directed  to  the  mouth.  Inspection  informs  us  of  its  pre- 
sence and  extent.  A  favorable  termination  may  be  confidently 
predicted,  unless  there  is  a  state  of  marked  cachexia,  or  a  grave 


ULCEROUS    STOMATITIS.  527 

coexisting  disease.  If  circumstances  are  unfavoral)lc,  simple 
stomatitis  may  terminate  in  a  more  severe  form,  as  tlie  ulcerous  or 
diphtheritic. 

Treatment. — The  physician  should  endeavor  to  ascertain  the 
cause,  and,  if  possible,  should  remove  it  by  appropriate  medicinal 
or  hygienic  measures.  Sometimes  no  special  treatment  is  required, 
as  in  measles  or  scarlet  fever.  When  the  j)rimary  aftection  termi- 
nates, the  stomatitis  disappears  of  itself.  If  dentition  is  the  cause, 
and  there  is  much  fever  and  frctfulness,  it  may  be  advisable  to 
scarify  over  the  advancing  tooth,  and  employ  such  soothing  and 
derivative  measures  as  are  required  in  painful  dentition.  In  these 
cases  mucilaginous  and  mild  astringent  lotions  may  be  employed. 
Borax  is  a  good  remedy  used  either  with  honey  or  water ;  one  part 
of  borax  to  three  of  honev,  or  a  drachm  of  borax  to  an  ounce  of 
water.  A  weak  solution  of  alum  is  also  a  good  topical  remedy. 
With  either  of  these  remedies  in  a  favorable  condition  of  system, 
and  without  any  serious  coexisting  disease,  the  stomatitis  is  relieved. 

Ulcerous  Stomatitis. 

In  ulcerous,  or,  as  designated  by  Eilliet  and  Barthez,  ulcero- 
membranous, stomatitis,  the  anatomical  characters  are  those  of 
severe  simple  stomatitis,  with  the  additional  element  which  gives 
it  the  name  by  which  it  is  designated. 

The  inflammation  usually  begins  upon  the  gums  and  extends 
along  the  buccal  surface.  Wherever  it  commences,  there  soon 
appear  little  white  points  underneath  the  mucous  membrane,  pro- 
ducing slight  prominence  of  it.  These  points,  which  are  inflam- 
matory exudations  mainly  fibrinous,  gradually  enlarge.  Some 
unite  and  give  rise  to  large  irregular  ulcerations ;  others  remain 
isolated,  producing  ulcers  which  are  smaller  and  of  more  regular 
shape.  There  is,  indeed,  no  uniformity  as  regards  the  size  and 
form  of  the  ulcers.  In  the  folds  of  the  buccal  membrane  they  are 
apt  to  be  elongated,  while  inside  the  lips,  or  where  the  surface  is 
smooth,  the  circular  or  oval  form  predominates. 

Ulcerous  stomatitis  is  usually  confined  to  that  part  of  the  buccal 
surface  which  covers  the  gums,  or  is  in  their  immediate  vicinity, 
but  in  some  instances  it  aftects  nearly  every  part  of  the  cavity  of 
the  mouth. 

If  the  disease  is  severe,  there  is  considerable  swelling  around 
the  ulcers,  but  the  swollen  part  is  soft  and  cushiony,  and  not  veiy 
tender  on  pressure.     The  soft  and  yielding  nature  of  the  swelling 


528  ULCEROUS    STOMATITIS. 

serves  as  a  means  of  diagnosis  between  tins  disease  and  the  pre- 
monitory stage  of  gangrene,  since  in  the  hitter  affection  the  swollen 
part  is  more  indurated. 

If  the  disease  grows  worse,  more  ulcers  appear;  the  fibrinous 
exudation  if  detached  is  renewed  or  it  becomes  thicker  by  the 
formation  of  new  layers.  The  ulcers  grow  deeper  and  wider,  and 
their  edges  more  vascular. 

If,  on  the  other  hand,  there  is  improvement,  the  swelling  sub- 
sides, the  ulcers  become  more  clean,  their  bases  approach  the  level 
of  the  mucous  membrane  and  present  a  granulating  appearance. 
Finally  the  mucous  membrane  is  reproduced.  A  considerable  time 
after  the  ulcers  are  healed,  the  new  membrane  which  occupies  their 
site  has  a  redder  hue  than  the  adjacent  surface. 

Causes. — Ulcerous,  like  simple,  stomatitis,  is  most  frequent  in 
the  families  of  the  poor.  Personal  uncleanliness,  poor  food,  a 
residence  in  apartments  dirty, humid,  or  in  other  respects  insalu- 
brious, favor  its  development.  In  fine,  a  cachectic  condition,  how- 
ever produced,  is  a  common  predisjDosing  cause.  It  frequently 
occurs  when  the  system  is  reduced  or  enfeebled  by  acute  diseases, 
as  after  the  essential  fevers  and  thoracic  and  intestinal  inflamma- 
tions. In  protracted  entero-colitis  of  infants,  it  is  sometimes  severe 
and  obstinate,  and  a  case  in  which  this  comjDlication  arises  usually 
ends  unfavorably. 

Occasionally  several  cases  occur  together  or  consecutively  in 
the  wards  of  a  hospital,  and  this  has  led  some  observers  to  be- 
lieve that  ulcerous  stomatitis  is  contagious.  But  its  prevalence 
under  such  circumstances  is  attributable  to  the  fact  that  there  is  a 
common  exposure  to  the  influences  which  give  rise  to  the  disease, 
just  as  a  whole  household  exposed  to  malaria  may  be  seized  with 
intermittent  fever.     Diflicult  dentition  is  also  an  occasional  cause. 

Symptoms. — The  symptoms  in  ulcerous  stomatitis  are  more  severe 
than  in  the  simple  form.  There  is  more  fever,  more  salivation, 
and  more  fretfulness.  The  ulcerated  surface  is  sometimes  very 
tender,  so  that  there  is  but  little  sleep.  Drinks,  unless  bland  and 
lukewarm,  are  painful,  and,  if  the  ulcers  are  on  the  lips  or  the  front 
of  the  mouth,  the  infant  nurses  less  eagerly  than  usual,  and  even 
with  reluctance,  sometimes  weaning  itself.  Occasionally  the  sub- 
maxillary glands  are  tumefied,  hard,  and  tender.  The  breath  has 
an  oflensive  odor.  In  mild  cases  in  which  the  stomatitis  is  of 
limited  extent,  this  odor  may  scarcely  be  noticed,  but  in  severe 
cases  it  is  almost  like  that  exhaled  from  putrid  substances. 


PROGNOSIS  —  TREATMENT.  529 

Prognosis. — A  ftivorablc  prognosis  may  be  given  unless  the 
patient  is  in  a  decidedly  cachectic  condition,  or  there  is  a  serious 
coexisting  disease,  under  which  circumstances  the  case  may  Ijc 
protracted.  If  death  occur,  it  is  due  to  the  cachexia  or  to  some 
pathological  state  quite  distinct  from  the  stomatitis,  most  fre- 
quently entero-colitis.  Ulcerous  stomatitis,  when  the  ulcers  are 
small  and  the  inflammation  of  limited  extent,  is  of  course  more 
easily  cured  than  when  it  is  extensive  and  the  ulcers  are  large. 

This  disease  is  very  liable  to  return,  unless  the  general  health  is 


good. 


Treatment. — The  physician  should  endeavor  to  ascertain  the 
cause  of  the  stomatitis,  and  so  far  as  possible  should  remove  the 
patient  from  its  influence.  It  is  often  necessary,  in  order  to  insure 
a  speedy  recovery,  to  recommend  a  change  in  regimen,  especially 
as  regards  diet  and  cleanliness.  If  the  patient  live  in  damp,  dark, 
and  dirty  apartments,  the  family  should  seek  a  better  residence, 
and  he  should  be  taken  daily  in  the  open  air. 

Tonic  remedies  are  generally  required.  The  ferruginous  pre- 
parations may  be  advantageously  given,  or  the  vegetable  tonics, 
or  the  two  in  combination.     In  selectino-  the  internal  remedies  we 

O 

must  regard  the  antecedent  disease,  if  there  be  any,  which  the 
buccal  inflammation  complicates,  and  on  which  it  depends.  For 
that  large  proportion  of  cases  in  which  there  is  chronic  intestinal 
inflammation,  the  liquor  ferri  nitratis  with  tincture  of  coluiubo 
administered  in  simple  syrup  will  be  found  useful.  For  local 
treatment  Trousseau  recommends  occasional  applications  of  nitrate 
of  silver  or  muriatic  acid  as  a  caustic,  and  in  the  intervals  a  wash 
of  equal  parts  of  borax  and  honey. 

The  chloride  of  lime  is  also  considerably  used  in  Paris.  It  is  re- 
commended by  Rilliet  and  Barthez.  It  is  applied  dry  to  the  ulce- 
rated surface  twice  daily,  and  in  the  interval  the  mouth  is  washed 
with  simple  water.  This  treatment  is  continued  till  the  ulcers 
present  a  healthy  appearance  and  begin  to  cicatrize.  Then  a  weak 
solution  of  chloride  of  lime  is  employed,  one  grain  to  forty-five  of 
the  vehicle.  By  this  treatment  a  cure  is  usually  efl'ected.  Bouchut 
prefers  using  chloride  of  lime  with  honey,  one  drachm  to  the 
ounce. 

But  painful  applications  are  not  required.  The  remedy  which 
is  most  employed  in  this  country  and  in  Great  Britain  is  chlorate 
of  potash.  It  often  acts  like  a  specific  for  this  as  well  as  other 
forms  of  stomatitis.  It  may  be  given  dissolved  in  water  with 
sugar,  or  with  one  of  the  syrups  to  render  it  more  palatable.  The 
U 


5'60  FOLLICULAR    STOMATITIS. 

dose  is  from  two  to  five  grains  every  two  hours.     It   should  be 

allowed  to  run  over  the  aiiected  part,  as  it  is  believed  to  have  a 

local  action. 

:^.  Potass.  Chlorat.  5j  ; 
Mellis  5SS  ; 
Aquog  5ij. 
One  teaspoonful  every  two  or  three  hours. 

Of  all  topical  remedies  in  common  use,  chlorate  of  potash  is  the 

most  safe,  most  easily  administered,  least  painful,  and  probably 
the  most  efficacious.  Some  physicians  prefer  the  chlorate  of  soda, 
on  account  of  its  greater  solubility. 

Follicular  Stomatitis. 

In  this  form  of  stomatitis  the  inflammation  is  confined  to  the 
muciparous  follicles  of  the  mouth,  or  to  them  and  the  mucous 
membrane  in  their  immediate  neighborhood. 

Anatomical  Characters. — At  first  there  appear  in  the  mouth 
minute  papular  elevations,  red,  hard,  and  tender,  which  continue 
to  enlarge  and  soon  become  vesicular.  They  may  now  break, 
leaving  an  ulcerated  surface ;  but  if  they  continue  entire  they  be- 
come purulent,  and  then  their  contents  are  discharged.  From  the 
commencement  of  the  papule  to  the  purulent  transformation  the 
period  is  perhaps  three  or  four  days. 

The  ulcer  which  occupies  the  site  of  the  eruption  is  round,  hard, 
painful,  and  with  a  vascular  margin.  The  base  has  a  white  or 
grayish  appearance.  The  reparative  process  soon  commences,  the 
ulcer  presents  a  healthy  appearance,  its  size  is  graduall}^  dimin- 
ished, and  finally  cicatrization  occurs. 

The  liquid  with  which  the  follicles  are  distended  in  the  first 
stages  of  the  disease  is  believed  to  be  the  natural  secretion  some- 
what modified  by  the  inflammation. 

The  number  of  ulcers  is  various.  There  are  in  most  cases  from 
six  or  eight  to  as  many  as  twenty.  They  are  ordinarily  discrete, 
and  one  or  two  lines  in  diameter.  The  stages  of  the  disease  rapidly 
succeed  each  other,  and  the  patient  fully  recovers  in  from  six  to 
eight  days,  but  not  always.  In  exceptional  instances  the  ulcers 
enlarge  and  become  confluent,  or  one  or  more  of  them  assume 
a  gangrenous  appearance.  This  indicates  a  faulty  condition  of  the 
system,  a  vitiated  state  of  the  blood,  due  perhaps  to  some  antece- 
dent or  concomitant  disease.  In  these  cases  the  ulcerative  stage  is 
apt  to  be  protracted,  and  recovery  doubtful. 


CAUSES— SYMPTOMS.  531 

The  seat  of  follicular  stomatitis  is  usually  the  internal  surface  of 
the  lips  and  cheeks,  the  gums,  tongue,  and  occasionally  the  roof 
of  the  mouth.  It  rarely  affects  the  fauces.  Occasionally  this  form 
of  stomatitis  is  associated  with  more  general  inflammation  of  the 
buccal  cavity.  The  gums  may  then  be  swollen  and  tender,  bleed- 
ing if  rubbed  or  pressed. 

Causes, — The  causes  are  not  fully  ascertained.  Follicular 
stomatitis  has  not  usually  in  my  practice  occurred  in  so  feeble  a 
state  of  system  as  has  been  present  in  ulcerous  stomatitis.  Billard, 
speaking  of  the  aphthce,  or  ulcers  of  this  disease,  says :  "  They  are 
particularly  to  be  seen  in  children  who  are  very  feeble,  pale,  and 
of  a  lymphatic  temperament.  "We  do  not  look  for  the  causes  of 
aphthse  in  the  retention  of  the  meconium,  acidity  of  the  milk,  or 
in  the  predominance  of  acidity  in  the  fluids  of  the  child;  we 
attach  more  importance  to  the  consideration  of  the  original  pre- 
dominance of  the  lymphatic  system,  or  rather  to  the  remarkable 
predominance  which  this  system  acquires  under  the  influence  of 
bad  nutrition  and  vitiated  air  which  is  respired  in  badly  ventilated 
places  in  those  who  are  crowded  together  with  a  number  of  sick 
children." 

Barrier  considers  follicular  stomatitis  to  be  allied  to  those  gas- 
tro-intestinal  diseases  which  are  attended  by  turgescence  of  the 
mucous  follicles,  and  he  mentions  among  the  causes  habitual  con- 
gestion of  the  buccal  mucous  membrane,  and  diflicult  dentition. 
In  most  cases  probably  the  exciting  cause  is  some  derangement 
of  the  digestive  organs  which  may  not  be  appreciable. 

While  simple  stomatitis,  and  stomatitis  with  thrush,  are  most 
common  under  the  age  of  six  months,  follicular  stomatitis  is  rare 
at  this  age.  It  is  most  frequent  during  the  time  which  corresponds 
with  dentition,  when  there  is  also  the  most  rapid  development  and 
greatest  activity  of  the  muciparous  follicles. 

Symptoms. — The  constitutional  symptoms  in  a  large  proportion 
of  cases  of  aphthfe  are  slight.  In  twelve  children  affected  with 
this  disease  Billard  found  the  pulse  from  sixty  to  eighty  beats  per 
minute. 

The  ulcers  are  painful,  as  is  indicated  by  the  cries  of  the  child 
when  they  are  pressed,  and  its  fretfulness.  Solid  food,  and  even 
drinks  unless  bland  and  unirritating,  are  badly  tolerated.  The 
salivary  secretion  is  also  augmented. 

In  those  rare  cases  in  which  the  ulcer  becomes  confluent  or 
gangrenous,  the  state  of  the  patient  is  really  serious.  There  is 
then  often  gastro-intestinal  disease.     The  symptoms  indicate  pros- 


532  FOLLICULAR    STOMATITIS. 

tratioii.     The  pulse  is  feeble,  the  countenance  pallid,  and  the  body 
and  limbs  become  wasted. 

Diagnosis. — This  is  easy.  The  only  disease  with  which  it  is 
liable  to  be  confounded  is  ulcerous  stomatitis.  In  the  ulcerous 
form  there  is  antecedent  and  accompanying  stomatitis  affecting  a 
considerable  part,  if  not  the  entire  buccal  cavity,  while  in  the 
follicular  form  the  inflammation  is  ordinarily  confined  to  the  im- 
mediate vicinity  of  the  ulcers.  The  character  of  the  ulcers  serves 
also  as  a  means  of  distinction.  In  ulcerous  stomatitis  there  is 
great  variety  as  to  size  and  form,  while  in  follicular  stomatitis 
there  is  great  uniformity  in  both  these  respects.  The  small,  cir- 
cular ulcers  are  characteristic  of  the  follicular  inflammation. 
Before  the  ulcerative  stage  the  vesicular  eruption  serves  to  distin- 
guish this  form  of  stomatitis  from  other  local  diseases  affecting 
the  cavity  of  the  mouth. 

Prognosis. — Follicular  stoijiatitis  usually  ends  favorably ;  but,  if 
the  ulcers  become  concrete  or  gangrenous,  the  health  is  seriously 
affected,  and  a  more  cautious  prognosis  should  be  expressed.  The 
unhealthy  appearance  of  the  mouth,  and  the  real  danger,  are  often 
more  due  to  the  depressing  effect  of  some  concomitant  disease  than 
to  the  stomatitis. 

Treatment. — In  ordinary  follicular  stomatitis,  which  is  dis- 
crete and  attended  by  little  or  no  constitutional  disturbance,  local 
remedies  sufiSce  to  cure  the  disease.  Demulcent  drinks,  or  appli- 
cations to  the  mouth,  should  be  used,  as  the  mucilage  from  gum 
acacia,  marsh-mallow,  or  flaxseed.  Mild  astringent  lotions  with 
the  demulcent  are  also  beneficial.  The  mel  boracis  is  one  of  the 
best  and  most  agreeable  applications.  It  may  be  placed  in  the 
mouth  with  a  spoon,  or  applied  with  a  camel-hair  pencil.  If  there 
is  much  tenderness  of  the  ulcers,  with  restlessness,  a  small  quantity 
of  some  opiate  should  be  added  to  the  lotion,  or  it  may  be  admin- 
istered separately. 

"With  this  simple  treatment  the  ulcers  generally  soon  heal,  and 
the  health  of  the  patient  is  restored.  If,  however,  the  ulcers  are 
quite  painful,  and  not  disposed  to  heal,  or  are  healing  tardily, 
they  may  be  touched  lightly  with  a  pencil  of  nitrate  of  silver,  or, 
as  Barrier  recommends,  hydrochloric  acid  in  honey  of  roses.  This 
diminishes  the  tenderness  and  expedites  the  healing  process. 

If,  as  may  in  rare  cases  occur,  the  ulcerations  are  numerous, 
and  are  accompanied  by  considerable  fever,  there  may  be  symp- 
toms indicative  of  cerebral  congestion,  or  even  premonitory  of 
convulsions.     In  such  cases  laxative  and  diaphoretic  remedies  are 


THRUSH  —  ANATOMICAL    CHARACTERS.  533 

required,  and  sinapisms  or  other  revulsive  applications  to  the  ex- 
tremities. 

If  there  is  an  unhealthy  appearance  of  the  ulcers,  if  they  gradu- 
ally enlarge,  or  become  concrete,  or  gangrenous,  indicating  a 
cachectic  state,  tonics  should  he  employed  with  nutritious  and 
easily  digested  diet,  and  anti-hygienic  influences  should  so  far  as 
possible  be  removed. 


CHAPTER  II. 

THRUSH. 

The  terms  thrush,  sprue,  and  muguet,  the  last  from  the  French, 
are  synonymous.  They  are  used  to  designate  a  jiarticular  form 
of  inflammation  of  the  digestive  apparatus,  the  peculiar  feature  of 
which  is  the  presence  of  points  or  patches  of  a  curd-like  appear- 
ance on  the  inflamed  surface. 

The  usual  seat  of  thrush  is  the  mucous  membrane  of  the  mouth, 
but  occasionally  it  aft'ects  the  fauces,  pharynx,  and  oesophagus.  It 
is  very  rare  in  the  sub-diaphragmatic  portion  of  the  digestive  tube, 
but  a  few  such  cases  have  been  reported  by  Billard  and  others.  It 
never  afi:ects  the  membrane  of  the  nostrils,  larynx,  or  bronchial 
tubes,  and  it  very  seldom  occurs  in  any  other  part  of  the  alimentary 
canal  without  also  being  present  in  the  mouth.  Thrush,  then,  is 
a  stomatitis,  pharyngitis,  or  cesophagitis,  or  a  gastro-enteritis,  with 
the  additional  element  which  I  have  described. 

Anatomical  Characters. — The  first  stage  of  thrush  is  that  of 
simple  inflammation  of  the  mucous  surface.  There  next  appear 
minute  semi-transparent  points  or  granules,  which,  increasing, 
soon  become  white  and  opaque.  Some  of  them  remain  as  points, 
while  others,  extending,  and  perhaps  coalescing  with  those  adjoin- 
ing, form  patches  of  greater  or  less  extent.  The  white  points  or 
patches  are  unequally  elevated.  Their  central  part,  which  was 
first  formed,  is  most  raised,  while  their  circumference  projects  but 
little  above  the  epithelium.  Their  highest  elevation  is  not  ordi- 
narily more  than  a  line  above  the  surface.  They  are  smaller  in 
the  pharynx  and  oesophagus  than  when  occurring  upon  the  buccal 
surface.  They  resemble  closely,  in  color  and  consistence,  portions 
of  curdled  milk,  and  the  nurse  often  mistakes  them  for  such,  and 
neglects  to  call  attention  to  the  state  of  the  mouth.     They  are 


534  '"  THRUSH. 

readily  detaclied  by  a  little  force,  but  are  speedily  reproduced. 
Their  color  in  tlie  first  days  of  the  complaint  is  white,  and  some- 
times this  color  continues.  In  other  cases  they  assume,  if  the  dis- 
ease is  protracted,  a  yellow  hue. 

Their  true  nature,  long  unknown,  was  finally  revealed  by 
microscopy.  They  consist  in  part  of  epithelial  cells,  and  in  part 
of  a  vegetable  growth.  This  parasitic  plant  is  in  most  cases  the 
oidium  albicans.  Like  other  confervse,  it  consists  of  roots,  branches, 
and  sporules.  The  roots  are  transparent,  and  they  penetrate  the 
epithelial  layer,  sometimes  even  to  the  basement  membrane.  The 
branches  divide  and  subdivide  at  an  acute  angle,  and  under  the 
microscope  they  are  seen  to  consist  of  elongated  cells,  with  one  or 
two  nuclei.  Around  these  branches  are  numerous  sporules.  In 
two  or  three  instances  I  have  examined  the  product  of  thrush 
removed  from  the  oesophagus,  and  in  both  the  parasitic  plant  was 
the  penicillium  glaucum,  or  a  conferva  closely  resembling  it. 

In  the  mildest  form  of  thrush,  this  morbid  product  is  in  points 
or  small  patches.  If  the  patches  are  of  large  extent,  especially  if, 
as  rarely  happens,  a  considerable  part  of  the  buccal  surface  is 
covered  by  them,  there  is  generally  a  state  of  great  prostration  and 
danger,  from  some  antecedent  or  concomitant  disease.  Thrush  is, 
indeed,  often  the  sequel  of  some  grave  affection,  as  pneumonitis 
or  gastro-intestinal  inflammation.  Its  complication  with  the  last 
named  disease  is  common  in  young,  ill-fed  infants,  especially  those 
deprived  of  the  breast  milk,  and  such  cases  are  very  apt  to  be 
fatal. 

Hence,  some  writers,  who  have  studied  infantile  diseases  in 
foundling  hospitals,  regard  thrush  as  one  of  the  most  serious  affec- 
tions of  early  life.  Valleix,  in  a  book  of  seven  hundred  pages  re- 
lating to  diseases  of  children,  devotes  more  than  one-third  to  the 
consideration  of  muguet.  Of  twenty-four  cases,  the  records  of 
which  he  publishes,  twenty-two  died,  but  their  death  was  due  to 
gastro-intestinal  inflammation,  which  the  author  considered  a  part 
of  the  more  general  disease,  muguet.  Doubtless  the  same  cause 
which  produced  the  stomatitis,  with  the  confervoid  growth,  in 
these  infants,  also  produced  the  fatal  gastritis  or  gastro-enteritis, 
occurring  without  this  growth  upon  the  gastric  or  intestinal  sur- 
face. It  seems  to  me  much  better  to  restrict  the  term  sprue,  thrush, 
or  muguet  to  the  inflammation  of  that  portion  of  the  mucous  sur- 
face which  is  the  seat  of  the  parasitic  growth.  I  reject,  then,  from 
my  description  of  the  anatomical  characters  of  thrush,  those  sub- 
diaphragmatic inflammations  which  some  writers  consider  an  im- 


SYMPTOMS  —  CAUSES.  535 

portantpart  of  tliis  disease,  and  place  them  in  the  list  of  coexisting 
aftections.  When  the  fatal  gastric  or  intestinal  inflammation  is 
accompanied  by  the  characteristic  vegetable  growth  on  the  gastric 
or  intestinal  surface,  it  is  i)roper  in  my  opinion  then,  and  only  then, 
to  say  that  death  occurred  from  thrush.  This  explanation  seems 
necessary  in  order  to  understand  the  dift'erent  statements  of  writers 
in  relation,  not  only  to  the  anatomical  characters  of  thrush,  but 
also  in  reference  to  its  mortality. 

The  frequent  coexistence  of  thrush  with  gastro-intestinal  inflam- 
mation, has  been  remarked  in  the  hospitals  of  Europe,  and  in  the 
Infant  Asylum  and  the  Child's  Hospital,  in  this  city.  In  the  post- 
mortem examinations  of  those  who  have  died  in  these  last  institu- 
tions, having  thrush  at  the  time  of  death  or  immediately  prior  to 
it,  and  who  for  the  most  part  have  been  infants  under  the  age  of 
three  months,  I  have  frequently  found  evidences  of  inflammation 
in  every  division  of  the  alimentary  canal.  The  confervoid  growth 
was,  however,  seldom  found  below  the  fauces,  and  never  below  the 
oesophagus. 

Symptoms. — The  symptoms  in  thrush  are  not  different  in  most 
cases  from  those  of  simple  inflammation.  In  the  mildest  cases 
they  are  chiefly  of  a  local  nature,  such  as  have  already  been  de- 
scribed in  our  remarks  on  simple  stomatitis.  If  the  inflammation 
is  more  extensive,  especially  if  it  affect  the  fauces  and  oesophagus, 
the  infant  becomes  feverish  and  fretful,  and  the  inflamed  surface 
is  hot,  red,  and  tender.  In  the  worst  forms  of  thrush  this  surface 
not  only  presents  the  ordinary  features  of  severe  inflammation, 
namely  heat,  redness,  and  tenderness,  but  it  is  sometimes  deficient 
in  the  natural  secretion,  so  as  to  present  a  dry  or  parched  appear- 
ance. It  is  in  these  cases  that  there  is  often  a  more  extensive  in- 
flammation than  that  of  the  buccal  or  oesophageal  membrane.  The 
sub-diaphragmatic  portion  of  the  digestive  tube  is  inflamed.  The 
infant  in  these  severe  cases  has  thirst,  loss  of  appetite,  restlessness, 
vomiting,  and  frequently  diarrhoea.  The  countenance  is  anxious 
and  pale ;  there  is  rapid  emaciation,  and,  if  the  disease  is  not  ar- 
rested, a  state  of  extreme  prostration  soon  occurs.  The  twenty-four 
severe  cases  related  by  Valleix,  already  alluded  to,  twenty-two 
of  which  were  fatal,  were  examples  of  this  severe  form. 

Causes. — Thrush  is  most  apt  to  occur  in  those  who  are  consti- 
tutionally feeble,  or  who  are  enfeebled  by  disease,  or  by  unfavor- 
able hygienic  conditions.  Cachexia  is  a  cause  common  to  thrush 
and  most  other  subacute  inflammations  of  the  alimentary  canal. 
The  most  obvious  and  common  of  the  unfavorable  hygienic  con- 


536  THRUSH. 

(litions  alluded  to  is  the  continued  use  of  indigestible  and  im- 
proper food.  It  is,  therefore,  a  common  disease  among  foundlings, 
in  institutions  where  these  unfortunates  are  received,  since  they 
not  only  breathe  an  atmosphere  which  is  often  impure,  but  are 
deprived  of  the  mother's  milk,  and  are  so  frequently  given  a  diet 
which  is  a  poor  substitute  for  it.  Among  the  poor  of  the  cities 
thrush  is  common,  since  with  them,  from  necessity  or  choice,  there 
is  the  greatest  neglect  of  sanitary  requirements.  Exposure  to  hu- 
midity, to  variations  in  temperature,  increases  the  liability  to  the 
disease,  though  in  less  degree  than  defective  alimentation.  Billard 
and  Valleix  agree  that  thrush  is  more  frequent  in  the  warm  months 
than  in  the  cold,  that  its  maximum  frequency  is  in  the  months  of 
July,  August,  and  September.  Cases  in  the  Infant  Asylum  and 
Child's  Hospital,  of  this  city,  have  appeared  to  me  to  correspond  in 
this  respect  with  those  related  by  Billard  and  Valleix.  Various 
w^riters  have  mentioned  the  age  at  which  thrush  is  most  apt  to 
occur,  as  one  of  the  2:)redisposing  causes.  Thrush  is  not  common 
above  the  age  of  six  months,  and  a  majority  of  the  cases  occur  under 
the  age  of  three  months.  Infants  of  the  age  of  one  or  two  weeks, 
if  in  addition  to  lactation  they  are  spoon-fed  by  nurses  over- 
anxious that  they  should  thrive,  are  ai:)t  to  take  the  disease. 

Diagnosis. — This  is  easy  so  far  as  thrush  in  the  mouth  is  con- 
cerned, for  simple  inspection  by  one  familiar  with  the  disease  is 
all  that  is  required  in  order  to  discover  it.  The  presence  of  thrush 
in  portions  of  the  alimentary  canal  hidden  from  view  cannot  be 
jwsitively  ascertained. 

The  vomiting,  diarrhoea,  pain  or  fretfulness,  emaciation,  and 
rapid  sinking,  which  sometimes  accompany  severe  forms  of  thrush, 
indicate  gastro-intestinal  inflammation,  to  which  the  attention  of 
the  practitioner  should  be  chiefly  directed. 

Prognosis. — The  duration  of  thrush  varies  according  to  its 
intensity,  and  the  favorable  or  unfavorable  condition  of  the  child. 
If  it  is  slight  and  the  health  of  the  infant  otherwise  good,  it  may 
often  be  cured  in  two  or  three  days.  Under  other  circumstances 
it  may  continue  as  many  weeks  or  even  longer,  before  it  is  entirely 
removed. 

When  thrush  occurs  in  connection  with  gastro-enteritis,  the 
mortality  is  very  great.  It  has  been  already  stated  that  in  Val- 
leix's  twenty-four  cases  twenty-two  were  fatal.  M.  Auvity  esti- 
mates the  mortality  of  such  cases  at  nine  in  ten,  and  M.  Godinat 
at  two  in  three. 

Treatment. — As  one  of  the  most  common  causes  of  thrush  is 
the  use  of  indigestible  or  improper  food,  the  physician  should 


TREATMENT.  537 

ascertain  the  nature  of  tlie  infant's  diet,  and  if  it  is  faulty  should 
direct  a  better.  In  many  cases  the  infant  is  bottle-fed.  It  should 
be  given  only  the  mother's  milk  if  practicable,  or  that  of  a  healthy 
wet-nurse.  This  change  of  alimentation  often  removes  the  sole 
cause  of  thrush  in  the  young  infant,  so  that  it  rapidly  recovers. 

If  artificial  feeding  is  necessary,  such  diet  should  be  advised  as 
is  directed  in  our  remarks  on  the  treatment  of  the  diarrhoeal 
maladies.  There  is  often  in  thrush  an  excess  of  acidity  in  the 
digestive  tube,  and  an  alkali  is  required.  Trousseau  recommends 
the  addition  of  saccharate  of  lime  to  the  milk.  Children  with 
this  disease  should  also  be  taken  from  filthy  and  damp  apartments, 
to  those  in  which  the  air  is  pure  and  dry. 

The  remedy  in  common  use  in  the  treatment  of  thrush,  and 

which  is  usually  effectual,  is  borax.     This,  if  api:)lied  sufliciently 

often  to  the  affected  membrane,  not  only  destroys  the  parasitic 

growth,  but  prevents  its  reproduction.     It  is  commonly  employed 

with  honey,  or  in  a  powder  with  sugar  or  dissolved  in  water.     The 

officinal  mel  boracis,  consisting  of  one  part  of  borax  to  eight  of 

honey,  is  so  much  used  in  families  that  it  may  be  considered  almost 

a  domestic  remedy.     There  is,  however,  an  objection  to  using  any 

ai:)plication  for  the  removal  of  thrush  which  contains  either  sugar 

or  honey,  since  either  substance  remaining  in  the  mouth  would 

rather  promote  the  growth  of  the  parasite.     Still,  it  is  desirable  to 

employ  a  wash  of  such  consistence  that  it  will  remain  a  longer  time 

in  contact  with  the  buccal  surface  than  will  a  simple  solution  in 

water.     I  know  no  better  vehicle  for  the  borax  than  glycerine, 

which  has  the  advantage  of  consistence,  does  not  readily  undergo 

any  chemical  change,  and  has  no  unpleasant  flavor.     The  borax 

may  be  used  dissolved  in  glycerine,  with  or  without  some  flavoring 

ingredient : — 

I^,     Sodre  borat.  5j  ; 
Glycerinse  ^ij  ; 
Aquae  5vj.     Misce. 

Borax  should  be  used  four  or  five  times  daily,  and  continued 
for  a  time  after  the  disease  has  disappeared  from  sight,  since  the 
roots  of  the  plant  must  be  destroyed  or  the  branches  are  rapidly 
reproduced.  It  should  be  applied  by  a  camel-hair  pencil,  or  with 
a  soft  cloth  upon  the  finger  or  a  stick.  It  should  be  so  freely 
used,  in  extensive  and  severe  forms  of  the  disease,  that  the  infant 
will  swallow  some,  as  the  entire  oesophagus  is  apt  to  be  afltected  in 
such  cases.  In  the  intervals  between  the  applications  of  borax, 
if  the  buccal  surface  is  hot,  dry,  and  tender,  so  as  to  increase  the 


538  GANGRENE  OF  THE  MOUTH. 

fretfulness  of  the  infant,  it  is  well  to  use  mucilaginous  washes,  as 
the  mucilao-e  of  acacia  or  mallows.  If  the  disease  continue  not- 
withstanding  the  use  of  these  measures,  the  mouth  should  be 
occasionally  washed  with  a  weak  solution  of  nitrate  of  silver  or 
sulphate  of  zinc  : — 

^.     Ziuci  sulpli.  gr.  ii-iv  ; 
Aq.  Rosse  gij.     Misce. 

In  many  cases,  however,  the  treatment  of  thrush  is  of  less  im- 
portance than  that  of  the  disease  which  the  thrush  complicates. 
The  remedial  measures  which  I  have  mentioned  then  become 
subordinate  to  those  employed  for  the  graver  disease.  When  this 
disease  is  relieved  and  the  general  health  improves,  thrush  is  more 
easily  and  permanently  cured  than  during  the  state  of  feebleness 
and  ill-health. 


CHAPTER   III. 

GANGRENE  OF  THE  MOUTH. 

The  diseases  of  the  mouth  which  we  have  been  considering  are 
attended  by  little  danger,  but  the  one  which  we  are  next  to  con- 
sider is  among  the  most  fatal  affections  of  early  life.  It  is  gan- 
grene of  a  portion  of  the  cheek  or  gums,  or  of  both.  It  is  described 
by  writers  under  various  names,  as  cancrum  oris,  noma,  necrosis 
infantilis,  aqueous  cancer  of  infants. 

Anatomical  Characters. — Gangrene  of  the  mouth  is  sometimes 
preceded  by  ulceration  of  the  mucous  meml)rane,  at  the  point 
where  it  is  about  to  commence,  but  in  other  cases  this  membrane 
is  entire.  The  tissues  at  the  point  of  attack,  which  is  most  fre- 
quently the  inside  of  the  cheek,  become  inflamed,  thickened,  and 
indurated.  The  induration  extends,  and  soon  the  purple  hue  of 
gangrene  appears  and  increases.  The  next  stage  in  the  progress 
of  gangrene  is  sloughing  of  the  portion  the  vitality  of  which  is 
lost. 

The  slough  does  not  present  the  appearance  of  uniform  decay. 
"While  the  color  is  generally  dark,  there  are  in  the  mass  fibres  of 
connective  tissue  or  even  bloodvessels,  which  remain  unchanged 
or  are  but  partially  decomposed.  After  separation  or  sloughing 
of  the  part  where  the  vitality  is  first  lost,  the  surface  of  the 


AGE.  539 

excavation,  if  the  disease  is  not  checked,  has  a  dark,  jagged,  and 
unhealthy  appearance.  Commencing  witli  tlie  mucous  membrane 
and  the  tissue  immediately  underlying  it,  the  disease  extends  on 
the  one  side  towards  the  skin,  and  on  the  other  towards  the 
deeper  seated  structures  of  the  jaw.  According  to  Billard,  the 
swelling  which  precedes  and  surrounds  the  gangrene  is  in  great 
part  oodematous. 

This  disease  is  occasionally  primary,  but  in  a  large  proportion 
of  cases  it  is  secondary.  Occurring  secondarily,  its  symptoms  are 
often  masked  by  those  of  the  antecedent  and  coexisting  aiiection. 
Under  such  circumstances  attention  is  sometimes  first  directed  to 
the  mouth,  by  the  loosening  of  one  or  more  of  the  teeth,  or  the 
appearance  on  the  skin  of  a  livid  circular  spot,  which  indicates 
the  approach  of  the  disease  to  the  cutaneous  surface.  The  mucous 
membrane  presents  a  dark  red  appearance  to  the  distance  of  a  few 
lines  beyond  the  point  of  gangrene.  It  covers  tissues  which  are 
inflamed  and  indurated  and  about  to  become  gangrenous. 

The  tongue  is  usually  more  or  less  swollen,  unless  the  disease 
is  mild ;  an  offensive  odor  arises  from  the  gangrene,  due  to  the 
evolution  of  sulphuretted  hydrogen  and  other  gases.  There  is 
great  difference  in  the  extent  of  the  destruction,  and  the  gravity 
of  the  disease,  in  different  cases.  It  may  sometimes  be  arrested  by 
proper  applications  and  a  favorable  change  in  the  general  health  of 
the  child  at  an  early  period,  when  there  is  little  loss  of  substance. 
In  other  cases  it  extends  till  it  perforates  the  cheek,  or  even 
destroys  a  considerable  part  of  the  side  of  the  face,  and,  extending 
inwards,  attacks  the  periosteum  of  the  maxillary  bone,  destroying 
the  gum  and  teeth,  and  denuding  the  alveoli.  Recovery,  if  it  take 
place  at  all  under  such  circumstances,  is  with  the  loss  of  a  portion 
of  the  bone,  and  with  deformity. 

The  duct  of  Steno  is  sometimes  included  in  the  gangrenous  por- 
tion, but  it  commonly  resists  the  destructive  process,  and  remains 
pervious. 

Age. — The  age  at  which  gangrene  of  the  mouth  occurs  is  usually 
between  two  and  six  years.  In  twenty-nine  cases  collated  by 
Rilliet  and  Barthez,  twenty -one  were  between  the  ages  of  two  and 
six  years,  and  the  remaining  eight  were  from  six  to  twelve  years 
old.  Of  the  cases  which  have  fallen  under  my  observation,  all 
were  between  the  ages  of  two  and  six  years.  It  is  seen  that  the 
period  of  greatest  frequency  of  gangrene  of  the  mouth  is  different 
from  that  at  which  the  ordinary  forms  of  stomatitis  occur. 

Gangrene  of  the  mouth  may,  however,  occur  under  the  age  of 


5i0  GANGRENE  OF  THE  MOUTH. 

one  year.  Billard  reported  three  cases  under  the  age  of  one  month, 
but  in  two  of  these  the  disease  does  not  appear  to  have  been 
sufficiently  marked  to  render  it  certain  that  they  were  genuine 
cases  of  this  aflection. 

Causes, — Gangrene  of  the  mouth  usually  occurs  in  those  whose 
sj^stems  are  reduced  or  cachectic.  It  is,  therefore,  more  frequent 
among  the  poor  than  those  in  comfortable  circumstances ;  in  the 
city  than  in  the  country.'  It  is  more  frequently  observed  in 
asylums  for  children  than  in  private  practice.  Half  the  cases 
which  I  have  seen  have  been  in  these  institutions.  If  the  consti- 
tution is  naturally  good,  it  can  only  occur  in  those  long  deprived  of 
pure  air  and  wholesome  nutriment,  or  those  enfeebled  by  disease. 

Among  the  diseases  which  have  been  known  to  terminate  in  or 
be  followed  by  gangrene  of  the  mouth,  are  the  pulmonary  and 
intestinal  inflammations,  hooping-cough,  and  the  fevers,  both 
eruptive  and  the  non-eruptive.  Rilliet  and  Barthez  have  pub- 
lished a  table  of  ninety-eight  cases  in  which  gangrene  resulted 
from  other  diseases.  In  forty-one  of  these  the  antecedent  disease 
was  measles,  in  five  scarlet  fever,  six  hooping-cough,  nine  inter- 
mittent fever,  nine  typhoid  fever,  seven  mercurial  salivation,  and 
five  enteritis.  It  is  seen  that  the  essential  fevers  were  the  most 
frequent  cause  of  the  gangrene.  Of  forty-six  cases  collected  by 
MM.  Bouley  and  Caillault,  the  antecedent  disease  was  measles  in 
all  but  five.  In  this  city,  also,  a  larger  number  occur  from  measles 
than  from  any  other  disease. 

One  reason  why  so  many  cases  of  gangrene  occur  as  a  sequel 
of  measles  is  probably  because  this  disease  is  accompanied  by 
stomatitis.     Simple  or  ulcerous  stomatitis  often  precedes  gangrene. 

Diseases  sometimes  terminate  in  gangrene  of  the  mouth  chiefly 
in  consequence  of  injudicious  treatment,  which  has  lowered  the 
vitality  of  the  system.  Rilliet  and  Barthez  mention  the  case  of  a 
child  four  years  old,  in  whom  gangrene  commenced  at  the  twenty- 
ninth  day  of  primitive  pneumonia.  This  child  had  been  reduced 
by  the  application  of  twelve  leeches,  three  scarifications,  a  large 
blister,  and  by  the  use  of  absolute  diet. 

The  misuse  of  mercury  was  once  a  much  more  frequent  cause 
of  gangrene  than  at  present,  at  least  in  this  country,  since  this 
agent  was  formerly  much  more  employed  than  now.  In  fact  most 
of  the  aftections  of  infancv  and  childhood  in  which  mercurials 
were  formerly  employed  are  now  treated  without  it. 

Symptoms. — Gangrene  of  the  mouth  so  often  occurs  in  connec- 
tion with  other  disease,  that  its  symptoms  are  in  a  large  propor- 


SYilPTOMS. 


41 


tion  of  cases  blended  with  those  which  arise  from  a  distinct 
pathological  state. 

There  is  usually  prostration  more  and  more  pronounced  as  the 
gangrene  extends.  The  features  are  ordinarily  pallid,  but  occa- 
sionally their  normal  color  is  preserved  for  a  time ;  the  expression 
of  the  face  is  melancholy  but  composed.  Sometimes  the  child  is 
fretful,  if  disturbed ;  at  other  times  it  will  quietly  consent  to  an 
examination.  The  suliering  is  not  proportionate  to  the  gravity  of 
the  disease.  There  is  less  pain  often  than  in  some  of  the  forms  of 
stomatitis  which  are  unattended  with  danger. 

As  the  disease  advances,  the  body  and  limbs  gradually  waste, 
the  eyes  are  hollow,  or,  if  the  gangrene  is  near  the  orbit,  the  eye- 
lids become  cedematous,  the  lips  are  infiltrated,  and  both  the  lips 
and  nostrils  are  often  incrusted.  If  the  cheek  is  perforated, 
alimentation  is  rendered  more  difficult,  and  the  appearance  of  the 
child  is  melancholy  in  the  extreme. 


The  tongue  is  usually  moist;  it  is  occasionally  swollen.  The 
saliva  flows  from  the  mouth,  either  pure  or  mixed  with  offensive 
sanguinolent  matter.  Unless  the  disease  is  slight,  there  is  the 
peculiar  gangrenous  odor.  The  appetite  is  sometimes  poor,  at 
other  times  it  is  preserved  through  the  whole  sickness.  There  is 
no  vomiting  or  looseness  of  the  bowels,  unless  from  a  complication. 


542  GANGRENE  OF  THE  MOUTH. 

The  thirst  is  usually  great,  and  the  pulse  is  accelerated  and  feeble, 
except  in  mild  cases. 

The  skin  in  the  commencement  of  gangrene  is  hot.  "When 
the  vital  force  is  much  reduced,  and  especially  as  the  disease 
approaches  a  fatal  termination,  the  face  and  limbs  become  cool, 
and  the  surface  generally  presents  a  waxen  or  ashy  appearance. 
There  is  no  derangement  of  the  respiratory  system.  Those  cases 
which  are  attended  by  a  cough  or  accelerated  respiration  are 
really  cases  of  bronchitis  or  pneumonitis,  coexisting  with  the  gan- 
grene. 

Diagnosis. — Gangrene  of  the  mouth  is  easily  diagnosticated. 
In  those  cases  in  which  ulceration  precedes  the  gangrene,  it  might 
be  mistaken  in  its  first  stages  for  that  form  of  ulcerous  stomatitis 
in  which  the  ulcers  assume  an  unhealthy  appearance.  The  follow- 
ing are  the  distinguishing  features  of  the  two  affections:  Around 
the  ulcer  where  gangrene  is  about  to  commence,  the  tissues  are 
greatly  thickened  and  indurated,  or  oedematous,  while  ulcerous 
stomatitis  begins  with  a  submucous  deposit  of  fibrin,  and  is  attend- 
ed by  little  thickening  of  the  surrounding  parts,  and  little  or 
no  induration  or  oedema.  In  ulcerous  stomatitis,  the  skin  over 
the  seat  of  the  disease  presents  its  normal  appearance,  whereas  in 
gangrene  it  presents  a  distended  and  shining  appearance.  The 
destructive  process  in  ulcerous  stomatitis  is  also  more  limited  than 
in  gangrene.  Deep  ulcerations  do  not  occur,  or  are  rare.  Ulcerous 
stomatitis  is  more  readily  healed,  and  it  leaves  no  eschar,  contrac- 
tion, or  deformity.  « 

The  difterential  diagnosis  of  gangrene  of  the  mouth,  from  those 
cases  of  follicular  stomatitis  in  which  the  ulcers  occupying  the  seat 
of  the  follicles  assume  a  gangrenous  appearance,  must  be  made  by 
a  consideration  of  the  same  facts  or  particulars  which  serve  to  dis- 
tinguish it  from  ulcerous  stomatitis. 

Malignant  pustule,  of  rare  occurrence  in  the  child,  resembles 
this  disease  in  some  of  its  features.  But  the  pustule  always  begins 
on  the  skin,  while  gangrene  is  a  disease  of  the  mucous  surface 
primarily.  In  gangrene,  therefore,  the  chief  destruction  is  of  the 
mucous  membrane  and  of  the  submucous  tissue,  while  in  malignant 
pustule  the  chief  destruction  is  of  the  skin  and  the  subcutaneous 
tissue. 

Prognosis. — This  depends,  not  only  on  the  extent  of  the  gangrene, 
but  the  nature  of  the  disease,  if  there  be  one,  which  gave  rise  to  it, 
and  the  degree  of  cachexia.  If  it  occurs  in  connection  with  or  as 
a  sequel  of  one  of  the  least  debilitating  diseases,  and  there  is  con- 


PROGNOSIS.  543 

siderable  vigor  of  system,  it  may  often  be  arrested  when  it  has 
destroyed  only  the  mucous  and  subcutaneous  tissues,  so  that  no  de- 
formity results.  The  friends  may  congratulate  themselves  if  the 
case  terminate  so  favorably.  In  the  graver  cases,  when  the  gan- 
grene extends  till  it  destroys  the  periosteum  of  the  maxillary  bone 
on  the  affected  side,  and  perhaps  perforates  the  cheek,  if  the  child 
recovers  it  is  with  the  permanent  loss  of  teeth,  tedious  separation 
of  the  necrosed  bone,  and  a  cicatrix,  which  is  aj)t  to  interfere  with 
the  free  use  of  the  jaw.  Death  is,  however,  the  more  common 
termination  of  severe  cases.  Occasionally  the  gangrene  destroys 
the  continuity  of  a  bloodvessel,  causing  abundant  hemorrhage,  and 
accelerating  the  fatal  result.  In  most  cases,  however,  there  is  little 
or  no  hemorrhage,  in  consequence  of  coagulation  in  the  vessels. 

Another  serious  complication  occasionally  arises,  namely,  gan- 
grene of  other  parts,  as  of  the  external  genital  organs.  The  English 
editor  of  Bouchut's  treatise  on  diseases  of  children,  relates  the  fol- 
lowing interesting  case,  from  the  Transactions  of  the  Edin.  Medico- 
Chir.  Society : — 

An  infant  eiffht  months  old  became  affected  with  gano-rene  of 
the  face,  head,  and  hands.  "  The  right  ear  and  the  entire  hairy 
scalp  were  of  an  intensely  black  color,  and  on  both  cheeks  patches 
existed  about  the  size  of  a  half-crown  piece.  The  right  thumb 
and  the  backs  of  both  hands  were  similarly  affected.  The  child 
was  noted  to  have  been  restless  and  feverish  on  May  22d,  and  on 
the  23d  a  slightly  darkened  ring  was  found  to  have  formed  round 
the  thumb,  about  the  middle  of  the  first  phalanx  ;  in  a  few  hours 
the  whole  thumb  was  gangrenous,  and  the  dorsum  of  the  hand  be- 
came involved.  On  the  ear  the  gangrene  commenced  with  the 
appearance  of  a  fleabite,  and  subsequently  extended  rapidly  to  the 
scalp,  assuming  a  remarkably  regular  form,  and  giving  to  the  child 
the  appearance  of  wearing  a  black  skullcap.  The  pulse  was  ob- 
served to  be  very  feeble.  *  *  *  Death  took  place  in  twelve 
hours  from  the  first  appearance  of  gangrene  on  the  thumb,  the 
child  being  sensible  and  continuing  to  suck  well,  vq)  to  a  few 
minutes  before  death." 

Rilliet  and  Barthez  state  that  pneumonitis  is  apt  to  arise  in  the 
course  of  gangrene  of  the  mouth.  Such  a  complication  evidently 
diminishes  materially  the  chance  of  recovery. 

"Whether  the  result  be  favorable  or  unfavorable,  it  is  evident, 
from  the  nature  of  the  disease,  that  the  duration  is  very  different 
in  different  cases.  The  physician's  attendance  may  be  required  for 
a  week  or  two  or  for  several  weeks. 


5i-i  GANGRENE    OF    THE    MOUTH. 

Treatment. — As  gangrene  of  the  mouth  is  eminently  a  disease 
of  debility,  all  anti-hygienic  influences  should  be  removed,  and  the 
most  nourishing  diet,  together  with  tonics,  be  recommended.  The 
ferruginous  preparations  or  the  bitter  vegetables  are  required. 

As  soon  as  the  physician  is  called,  he  should  endeavor  to  arrest 
the  gangrene,  accelerate  the  detachment  of  the  slough,  and  pro- 
duce a  healthy  and  granulating  state  of  the  surrounding  tissues. 
This  is  best  effected  by  applying  a  highly  stimulating  or  even 
escharotic  agent  to  the  inflamed  surface  underneath  and  around 
the  gangrene.  For  this  purpose  a  great  variety  of  substances 
have  been  used  by  difierent  physicians,  such  as  acetic,  sulphuric, 
nitric,  and  hydrochloric  acids,  nitrate  of  silver,  the  acid  nitrate  of 
mercury,  chloride  of  antimony,  and  even  the  actual  cautery. 

M.  Taupin  recommends,  after  removing  a  considerable  part  of 
the  gangrenous  substance  with  scissors  or  some  instrument,  the 
application  of  strong  muriatic  acid,  and,  when  the  slough  is  de- 
tached, of  dry  chloride  of  lime. 

Eilliet  and  Barthez  advised  the  use  twice  daily  of  muriatic  acid 
or  the  acid  nitrate  of  mercury,  applied  by  a  brush  upon  and 
around  the  slough,  followed  immediately  by  the  application  of 
dry  chloride  of  lime,  when  the  mouth  is  to  be  thoroughly  washed 
with  water  from  a  syringe.  They  direct  in  the  interval  frequent 
ablution  with  water.  After  the  slough  has  separated,  the  escharotic 
is  to  be  discontinued,  and  the  chloride  of  lime  used  alone.  If 
o-ano-rene  extends  to  the  skin,  a  crucial  incision  is  to  be  made  and 
the  escharotic  applied,  after  which  powdered  cinchona  is  intro- 
duced and  retained  by  a  plaster.  This  treatment  is  to  be  continued 
till  the  gangrene  is  arrested  and  the  decayed  portion  removed. 
Barrier,  Valleix,  and  most  French  writers,  recommend  essentially 
the  same  treatment,  namely,  the  application  of  undiluted  escharotic 
assents. 

CD 

A  safer,  less  painful,  and,  in  my  opinion,  preferable,  treatment, 
is  that  employed  by  many  British  and  American  physicians, 
namely,  the  use  of  escharotic  agents  diluted,  or,  if  applied  in  their 
full  strength,  such  as  are  least  active  and  penetrating.  Some 
employ  from  the  first  topical  treatment  which  is  astringent  and 
stimulating  rather  than  escharotic,  and  they  report  satisfactory 
results. 

Dr.  Gerhard  believes  "  the  best  local  applications  are  the  nitrate 
of  silver,  if  the  glough  be  small  in  extent ;  if  much  larger,  the 
best  escharotic  is  the  muriated  tincture  of  iron,  applied  in  the 
undiluted  state.     After  the  progress  of  the  disease  is  arrested,  the 


TREATMENT.  545 

ulcer  will  improve  rapidly  under  an  astringent  stimulant,  siicli  as 
the  tincture  of  myrrh,  or  the  aromatic  wine  of  the  French  Phar- 
macopceia." 

The  local  treatment  recommended  by  Evanson  and  Maunsell  I 
believe  to  be  preferable  to  that  advised  by  any  of  the  writers  from 
whom  I  have  quoted.  I  have  seen  it  so  successful,  that  I  should 
employ  it  in  all  ordinary  cases  from  the  first  visit.  A  knowledge 
of  this  treatment  will  be  best  imparted  by  quoting  from  the 
authors  (Diseases  of  Children,  2d  Amer.  edit.,  page  188):  "The 
lotion  which  we  have  found  by  far  the  most  successful  is  a  solu- 
tion of  sulphate  of  copper  as  employed  by  Coates  in  the  Children's 
Asylum.     His  formula  is  as  follows: — 

"^.     Cupri  sulph.  3ij  ; 

Pulv.  cinchonae  ^ss ; 
Aquae  ^iv.     M. 

"This  is  to  be  applied  twice  a  day  very  carefullj^  to  the  full 
extent  of  the  ulcerations  and  excoriations.  The  addition  of  the 
cinchonae  is  only  useful  by  retaining  the  sulphate  of  copper  longer 
in  contact  with  the  edges  of  the  gums.  A  solution  of  the  sulphate 
of  zinc,  5j  to  an  ounce  of  water,  by  itself  or  combined  with  tinc- 
ture of  myrrh,  Dr.  Coates  found  to  be  also  useful  in  some  cases." 

A  moment's  reflection  will  show  us  that  the  above  treatment  is 
far  preferable,  provided  it  is  equally  efiectual  in  arresting  the  gan- 
grene, to  the  treatment  by  the  strong  escharotics  which  some  of 
our  best  practitioners  employ. 

Take,  for  example,  the  use  of  pure  nitric  or  muriatic  acid,  which 
physicians  of  experience  recommend.  This  agent  causes  such  pain 
that  it  occasions  restlessness  of  the  child,  and  such  stout  resistance 
that  the  use  of  chloroform  has  been  recommended  to  facilitate  its 
application.  The  j)ain  occurring  from  it  and  from  the  inflamma- 
tion which  it  excites  doubtless  reduces  the  strength  which  it  is 
very  necessary  to  preserve.  If  the  acid  comes  in  contact  with  the 
teeth,  as  it  generally  will,  it  injures  them  irreparably,  and  it  some- 
times attacks  the  jaw-bone.  Dr.  West,  who  advocates  the  use  of 
the  acid  (Diseases  of  Infancy  and  Childhood,  4th  Amer.  edit.,  page 
467),  says :  "  In  one  of  the  cases  that  I  saw  recover,  the  arrest  of 
the  disease  appeared  to  be  entirely  owing  to  this  agent,  though  the 
alveolar  processes  of  the  left  side  of  the  lower  jaw  from  the  first 
molar  tooth  backwards  died  and  exfoliated,  apparently  from  having 
been  destroyed  by  the  acid."  ISTo  such  result  follows  the  use  of  the 
solution  of  sulphate  of  copper,  and  of  its  efficacy  I  can  speak  con- 
35 


5-i6  DENTITION. 

fidently.  In  one  of  those  severe  cases  in  which  the  disease  resulted 
from  scarlet  fever,  and  in  which  there  was  so  much  debility  that 
an  unfavorable  prognosis  was  made,  I  succeeded  in  arresting  the 
disease  by  the  use  of  Dr.  Coates'  prescription.  The  child  recovered 
with  the  loss  of  two  teeth,  and  the  corresponding  portion  of  the 
maxillary  bone. 

The  application  should  be  made  twice  a  day  till  the  gangrene 
is  arrested,  and  healthy  granulations  appear. 

The  gases  arising  from  the  gangrenous  mass  are  not  only  highly 
oftensive  to  others,  but  they  are  doubtless  injurious  to  the  patient, 
who  is  constantly  inhaling  them.  To  remove  the  fetor  chlorine  or 
carbolic  acid  properly  diluted  should  be  occasionally  used  between 
the  applications  of  the  sulphate  of  copper.  Labarraque's  solution, 
one  part  to  eight  or  ten  parts  of  water,  is  an  eligible  form  for  its 
use.  When  the  gangrene  is  removed,  and  the  granulations  present 
a  healthy  appearance,  all  danger  is  usually  past,  and  convalescence 
is  fully  established.  Then  no  energetic  topical  treatment  is  re- 
quired. A  mild  stimulating  lotion,  like  the  tincture  of  myrrh,  as 
recommended  by  Dr.  Gerhard,  suffices  with  the  aid  of  tonics  and 
nutritious  diet. 


CHAPTER  IV. 

DENTITION. 

The  part  which  dentition  bears  in  the  causation  of  disease  is 
not  fully  ascertained.  We  know  that  the  opinion  formerly  enter- 
tained in  the  profession,  and  now  prevalent  in  the  community,  that 
a  large  proportion  of  the  affections  of  infancy  arise  directly  or 
indirectly  from  it,  is  erroneous.  Still,  many  of  the  best  authorities 
in  infantile  pathology  concur  in  the  belief  that  difficult  and  pain- 
ful evolution  of  the  teeth  frequently  causes  derangement  in  the 
functions  of  organs,  even  those  remote  from  the  mouth,  and  some- 
times produces  in  them  a  real  pathological  state.  They,  therefore, 
frequently  speak  of  dentition  as  a  cause  of  disease.  On  the  other 
hand,  there  are  physicians  equally  good  observers,  and  the  number 
is  increasing,  who  almost  wholly  ignore  the  pathological  results  of 
dentition.  They  say  that,  as  it  is  strictly  a  physiological  process, 
it  should,  like  other  such  processes,  be  excluded  from  the  domain 
of  pathology.     Experience,  they  assert,  corroborates  this  opinion, 


DENTITION.  547 

and  therefore  dentition  should  seldom,  if  ever,  be  interfered  with 
by  the  lancet  or  other  means. 

A  moment's  reflection  will  show  how  important  it  is  to  under- 
stand the  exact  relation  of  dentition  to  infantile  diseases.  Every 
physician  is  called  now  and  then  to  cases  of  serious  disease,  in- 
flammatory and  others,  which  have  been  allowed  to  run  on  with- 
out treatment,  in  the  belief  that  the  symptoms  were  the  result  of 
dentition.  I  have  known  acute  meningitis,  pneumonitis,  and  entero- 
colitis, even  with  medical  attendance,  to  be  overlooked  during  the 
very  time  when  appropriate  treatment  was  most  urgently  demanded. 
Many  lives  are  lost  in  this  manner,  especially  from  neglected  en- 
tero-colitis,  the  friends  and  even  physicians  believing  the  diarrhoea 
to  be  symptomatic  of  dentition,  a  relief  to  it,  and  therefore  not  to 
be  treated.  Such  mistakes  are  traceable  to  the  erroneous  doctrine, 
long  inculcated  in  the  schools,  that  dentition  is  directly  or  indi- 
rectly the  cause  of  a  large  proportion  of  infantile  diseases  and  de- 
rangements. 

May  there  not  be  an  error  in  the  opposite  direction?  May  not 
some  diseases  be  rendered  milder,  and  their  favorable  termination 
more  certain  or  probable,  by  measures  calculated  to  relieve  the 
turgescence  of  the  gums  ?  If  so,  those  who  totally  disregard  the 
state  of  the  gums  are  not  less  in  error  than  those  who  use  the  gum 
lancet  when  it  is  not  required. 

I  shall  endeavor  to  point  out  what  is  really  ascertained  in  regard 
to  the  relation  of  dentition  to  disease. 

First  dentition  commences  at  the  age  of  about  six  months  and 
terminates  at  the  age  of  two  and  a  half  years.  The  corresponding 
teeth  of  the  two  sides  pierce  the  gum  at  about  the  same  time.  The 
two  inferior  central  incisors  first  appear  at  about  the  age  of  six  or 
seven  months,  followed,  in  the  order  in  which  they  are  mentioned, 
by  the  upper  central  incisors,  upper  lateral  incisors,  lower  lateral 
incisors,  the  four  anterior  molars,  the  four  canines,  and,  lastly,  the 
four  posterior  molars. 

The  incisors  usually  appear  in  rapid  succession,  so  that  all  are 
in  sight  by  the  age  of  one  year.  From  the  age  of  one  year  to  six- 
teen months  the  anterior  molars  penetrate  the  gum,  from  the  age 
of  sixteen  to  twenty-four  months  the  canines,  and  from  twenty- 
four  to  thirty  months  the  posterior  molars. 

This  order  is  not  always  preserved.  Sometimes  the  upper  cen- 
tral incisors  appear  before  the  lower,  and  sometimes  the  lower 
lateral  before  the  upper  lateral.  In  rare  cases  there  have  been 
teeth  at  birth.     I  have  seen  but  one  or  two  infants  with  such  pre- 


5i8  DENTITION. 

mature  dentition.  Retarded  dentition  is  much  more  common. 
Those  who  have  rickets,  or  are  feeble  either  constitutionally  or  by 
disease,  often  have  no  teeth  till  considerably  after  the  usual  period. 
In  such  the  first  incisors  may  not  appear  till  the  age  of  twelve 
months,  or  even  later. 

Pathological  Results  of  Dentition. — The  evolution  of  the 
teeth  is  commonly  attended  by  more  or  less  turgescence  around 
the  dental  bulbs.  This  is  greater  with  some  of  the  teeth  than 
with  others.  Thus,  the  superior  incisors  cause  more  swelling  than 
do  their  congeners  of  the  inferior  jaw.  The  turgescence,  although 
it  may  be  attended  by  more  or  less  congestion,  is  so  common  that 
it  is  hardly  proper  to  call  it  a  disease.  Turgescence,  with  redness 
and  more  or  less  tenderness  of  the  swollen  gum,  may  be  considered 
the  simplest  pathological  state. 

In  other  cases  there  is  an  unusual  amount  of  swelling  around 
the  dental  follicles,  the  afflux  of  blood  to  them  is  greatly  aug- 
mented ;  they  are  the  seat  of  such  a  degree  of  tenderness  and  pain 
that  the  infant  is  fretful.  It  carries  the  finger  often  to  the  mouth, 
indicating  the  seat  of  its  suffering.  The  surface  over  the  folli- 
cles presents  greater  redness  than  in  ordinary  dentition,  and  the 
salivary  secretion  is  considerably  increased.  There  is  now  actual 
gengivitis. 

Sometimes  the  inflammation  affects  a  greater  extent  of  the 
buccal  surface  than  that  lying  directly  over  the  follicles,  so  that 
most  writers  speak  of  stomatitis  as  one  of  the  results  of  dentition. 
In  a  few  cases  I  have  known  such  a  degree  of  inflammation  over 
the  advancing  tooth,  that  a  small  abscess  formed,  producing  much 
pain  and  restlessness,  till  it  was  opened  by  the  lancet. 

The  pathological  results  of  dentition  which  I  have  mentioned 
are  unimportant  in  comparison  with  others  not  yet  alluded  to. 
They  do  not  endanger  the  life  of  the  child.  They  are  easily 
detected.  They  result  directly  from  the  rapid  growth  and  aug- 
mented sensibility  of  the  dental  follicles. 

There  are  other  accidents  of  dentition  occurring  in  distant  parts 
of  the  system  in  consequence  of  that  mysterious  relation  and 
interdependence  of  organs  which  exist  through  the  system  of 
nerves. 

These  accidents  are  more  serious,  and  their  relation  to  dentition 
is  obviously  less  readily  ascertained,  than  are  those  located  in  the 
mouth.  The  most  common  of  them  occur  in  the  stomach  and 
intestines. 

Some   children,  previously  to  the   eruption  of  the   teeth,  are 


PATHOLOGICAL    RESULTS    OF    DENTITION.  549 

affected  with  di.arrhoca,  occasionally  accompanied  by  irritability 
of  stomach.  Certain  writers  have  supposed  that  gastro-intestinal 
inflammation  is  present  in  these  cases ;  others  that  there  is  simply 
a  hyper-secretion,  an  increased  activity  of  the  intestinal  follicular 
apparatus,  that  it  is,  in  other  words,  one  of  the  forms  of  non- 
inflammatory diarrhrea.  Barrier  believes  that  the  diarrhoea  of 
dentition  depends  usually  on  what  he  calls  a  "  subinflammatory 
turgescence  limited  to  the  gastro-intestinal  follicular  apparatus." 
He  believes  that,  in  occasional  cases,  it  is  due  to  defective  or  altered 
innervation.  It  would  then  be  analogous  or  similar  to  that  form 
of  diarrhoea  which  occurs  in  the  adult  from  the  emotions.  Bouchut 
calls  the  diarrhoea  of  dentition  nervous  diarrhoea.  It  is  certain, 
however,  that  in  most  cases  of  diarrhoea  which  are  attributed  to 
dentition  there  are  other  causes,  such  as  unsuitable  food,  or 
residence  in  an  insalubrious  locality.  It  is  certain,  as  regards  city 
infants,  that  the  chief  causes  of  diarrhoea  during  the  period  of 
dentition  are  strictly  anti-hygienic,  dentition  being  quite  subordi- 
nate as  a  cause,  and  probably  often  not  operating  at  all  as  such. 
But  when,  as  sometimes  happens,  at  each  period  of  dental  evolu- 
tion, the  infant  is  aflfected  with  diarrhoea,  the  influence  of  teething 
is  apparent.  Such  cases  enable  us  to  see  that  teething  may  really 
sustain  a  causative  relation  to  certain  diseases  not  located  in  the 
buccal  cavity. 

Among  the  most  common  pathological  results  of  difficult  den- 
tition, are  certain  aflfections  referable  to  the  cerebro-spinal  system. 
Eclampsia  is  one  of  the  admitted  results.  Barrier  attributes  con- 
vulsions in  the  teething  infant  to  excitement  of  the  nervous  sj^stem 
arising  from  the  pain  which  is  felt  in  the  gums,  and  to  a  determi- 
nation of  blood  to  the  dental  apparatus,  in  which  afflux  the  whole 
vascular  system  of  the  head  participates. 

In  most  cases  of  convulsions  occurring  during  the  period  of 
dental  evolution,  a  careful  examination  discloses  other  causes  in 
addition  to  the  state  of  the  gums.  Difficult  dentition  must  then 
be  considered,  not  so  frequently  a  direct  as  a  co-operating  or  pre- 
disposing cause,  producing  a  sensitive  state  of  the  nervous  system, 
or  possibly  an  afflux  of  blood  to  the  head,  of  which  Barrier  speaks, 
and  which,  by  an  additional  stimulus,  perhaps  trivial  in  itself, 
ends  in  convulsions.  In  exceptional  instances  eclampsia  occurs 
mainly  from  dentition,  or,  if  there  are  other  causes,  they  are  quite 
subordinate.  This  may  happen  when  several  teeth  penetrate  the 
gum  at  or  about  the  same  time.  Infants  who  are  burnt  or  scalded 
are  very  liable  to  clonic  convulsions.     This  is,  in  fact,  the  chief 


550  DENTITION. 

dano-er  as  res-ards  life  from  such  accidents.  So,  the  swollen  and 
tender  gum,  if  several  teeth  are  about  emerging,  may  aifect  the 
cerebro-spinal  system  like  the  burn  or  scald,  and  produce  the 
same  nervous  phenomena.  Thus,  in  a  case  already  alluded  to  in 
the  chapter  on  convulsions,  five  incisors  pierced  the  gum  within 
about  two  weeks,  and  in  this  period  there  were  two  attacks  of 
eclampsia  with  an  interval  of  a  few  days.  The  attacks  were  not 
severe,  and  the  most  careful  examination  could  discover  no  other 
cause  than  the  simultaneous  development  of  so  many  dental 
follicles.     Previously,  and  since,  the  infant  has  been  well. 

Dentition  sometimes,  though  rarely,  occasions  also  tonic  convul- 
sions. The  following  case  occurred  in  the  practice  of  Dr.  A.  S. 
Church,  of  this  city,  the  history  of  which  he  has  kindly  commu- 
nicated, as  follows : — 

"H.,  seven  months  old,  was  first  visited  April  3d,  1863.     The  patient 
had  been  fretful  for  several  days,  but  about  daylight  on  the  morning  of 
my  first  visit  it  commenced  crying,  and  had  not  ceased  for  a  moment  at 
the  time  of  my  visit,  9  A.M.     The  bowels  were  somewhat  constipated 
and  tympanitic;    abdominal  muscles  very  tense.      The  pain  was  sup- 
posed to  be  in  the  abdomen,  and  a  brisk  catliartic,  to  be  followed  by 
an  anodjaie,  was  ordered.     Some  relief  followed,  but,  on  the  ensuing 
and  for  several   consecutive   mornings,  the   pain  'returned,  each   day 
lasting  longer,  until  the  child  only  ceased  crying  while  under  the  in- 
fluence of  a  full  anodj'ne.     The  gum  over  the  upper  incisors  was  con- 
siderably swollen,  hot,  and  dry,  but  the  parents  would  not  consent  to 
have  it  scarified.     For  the  first  week  there  was  no  fever,  no  vomiting, 
and  not  the  least  indication  that  the  nervous  system   was  suffering. 
About  the  10th  the  thumbs  were  noticed  to  be  flexed  during  the  attack 
of  pain,  and  about  the  15th  the  flexors  of  the  toes  were  contracted  and 
the  hands  were  turned  backwards  and  outwards,  but  only  while  the  child 
was  awake.     About  the  20th  there  was  constant  contraction  of  the  flexors 
of  both  extremities,  with  opisthotonos,  and  constant  rolling  of  the  head, 
loss  of  appetite,  progressive  emaciation,  coated  tongue,  and  highly  in- 
flamed gums.      Consent  was,  finally,  obtained  to  relieve  the  inflamed 
gum,  and  free  incisions  were  made,  and  the  following  night  the  child 
slept  comfortably  for  three  hours  without  opiates.     In  three  days  the 
gums  were  freely  cut  again,  and  the  teeth  soon  made  their  appearance. 
AH  symptoms  of  disease  had  now  ceased,  the  child  became  playful,  and 
on  the  30th  the  patient  was  discharged." 

The  opinion  has  been  prevalent  in  the  profession,  that  painful  and 
difiicult  dentition  is  one  of  the  chief  causes  of  infantile  paralj^sis, 
but  it  is  now  commonly  admitted  that  it  is  only  a  subordinate  or 
remote  cause  if  indeed  it  is  proper  to  consider  it  as  a  cause  at  all 
(see  Art.  Paralysis). 

Some  writers  express  the  opinion  that  acute  meningitis  occa- 
sionally results  from  teething.     The  facts,  however,  that  are  relied 


DIAGNOSIS  —  TREATMENT.  551 

upon  to  prove  tliis  arc  iiiicertaiu.     The  occurrence  of  meningitis 
during  dentition  is  probably  in  most  instances  a  coincidence. 

Teething  less  frequently  disturbs  the  respiratory  system  than 
either  the  digestive  or  cerebro-spinal.  A  cough  occurs  in  some 
infants  at  each  period  of  dental  evolution.  It  is  attended  by  little 
expectoration,  but  appears  to  be  associated  with,  in  at  least  cer- 
tain cases,  an  inflammatory  turgescence  of  the  bronchial  mucous 
membrane. 

Acceleration  of  jmlse  is  often  observed  at  the  time  of  greatest 
swelling  and  tenderness  of  the  gum.  It  subsides  with  the  pro- 
trusion of  the  tooth.  The  febrile  movement  of  dentition  is  ir- 
regular, sometimes  presenting  a  remittent  form,  like  remittent 
fever  or  the  fever  premonitory  of  meningitis.  Eczema  and  certain 
other  cutaneous  diseases  are  common  during  dentition,  but  their 
dependence  on  it  as  a  cause  has  not  been  demonstrated. 

Diagnosis. — The  accidents  of  dentition  which  are  located  in  the 
mouth  are  easily  diagnosticated,  except  the  odontalgia  which 
writers  describe,  and  which  is  not  necessarily  attended  by  any 
perceptible  anatomical  alteration  of  the  gums.  Those  accidents 
which  pertain  to  remote  and  concealed  organs  are  usually  detected 
with  ease,  though  it  is  often  difficult  to  determine  with  certainty 
their  relation  to  dentition. 

When  similar  symptoms  arise  at  each  epoch  of  teething,  and 
subside  with  the  subsidence  of  the  gengival  turgescence,  teething 
must  be  regarded  as  the  cause.  Or,  if  the  disease  is  such  as  is 
known  to  be  produced  occasionally  by  difficult  teething,  and  if, 
after  a  careful  examination,  we  can  discover  no  other  cause,  while 
the  gums  are  swollen,  especially  over  two  or  more  advancing  teeth, 
it  is  proper  to  refer  the  disease  to  dentition. 

It  is  evident  that  we  must  often  be  in  doubt  whether  the  disease 
which  we  are  treating  is  due  at  all  to  the  state  of  the  gums,  or,  if 
so,  whether  directly  or  indirectly,  or  to  what  extent ;  but,  as  a  rule, 
if  any  other  cause  is  apparent,  we  may  properly  regard  the  influ- 
ence of  dentition  as  quite  subordinate. 

Treatment. — It  is  obvious  that  remedial  measures  in  cases  of 
difficult  dentition  must  be  twofold,  namely,  those  directed  to  the 
state  of  the  gums,  and  those  designed  to  relieve  the  derangements 
or  diseases  to  which  dentition  has  given  rise.  If  there  is  diarrhoea, 
this  should  be  controlled  by  proper  remedies,  so  as  to  reduce  the 
number  of  evacuations  to  two  or  three  daily.  It  is  well  to  state 
to  the  friends  of  the  child,  who  believe  that  diarrhoea  is  salutary 
during  the  period  of  teething,  that  this  number'is  quite  sufficient. 


552  DENTITION. 

and  that  more  frequent  evacuations  will  endanger  the  safety  of  the 
child. 

The  nervous  affections,  as  convulsions,  require  such  soothing 
and  derivative  measures  as  are  recommended  in  our  remarks  on 
diseases  of  the  nervous  system.  The  bromide  of  potassium  I  have 
found  especially  useful  and  safe  in  cases  of  fretfulness  and  nervous 
excitement  due  to  dentition.  The  rational  employment  of  thera- 
peutic measures  requires  strict  attention  to  be  given  to  the  causes 
of  disease.  Therefore,  the  physician  called  to  treat  an  ailment, 
believed  to  be  due  to  dentition,  should  not  fail  to  examine  the 
state  of  the  gums,  and  adopt  such  measures  as  will  mitigate  the 
intensity  of  the  cause — in  other  words,  diminish  the  tenderness  if 
not  the  swelling  of  the  gum.  Demulcent  and  soothing  lotions  are 
recommended  by  some.  The  infant  should  be  allowed  to  hold  in 
the  mouth  an  India-rubber  or  ivory  ring,  which  by  pressure  on  the 
gum  gives  considerable  relief. 

Mothers  will  often  attempt  to  "  rub  through  a  tooth,"  as  they 
term  it,  by  means  of  a  ring  or  thimble.  This  should  be  discour- 
aged. So  great  friction  cannot  fail  to  have  an  injurious  effect,  by 
increasing  the  swelling  and  inflammation,  unless  the  tooth  has 
already  reached  the  mucous  membrane. 

We  come  now  to  a  subject  which  has  engaged  the  attention  of 
many  of  the  ablest  and  most  experienced  physicians,  and  in  refer- 
ence to  which  there  is  still  a  difference  of  opinion  among  the 
highest  authorities  in  medicine.  I  refer  to  scarification  of  the 
gums. 

The  gum  lancet  is  now  much  less  frequently  employed  than 
formerly.  It  is  used  more  by  the  ignorant  practitioner,  who  is 
deficient  in  the  ability  to  diagnosticate  obscure  diseases,  than  by 
one  of  intelligence,  who  can  discern  more  clearly  the  true  patho- 
logical state.  Its  use  is  more  frequent  in  some  countries,  as  Eng- 
land, under  the  teaching  of  great  names,  than  in  others,  as  France, 
where  the  highest  authorities,  as  Rilliet  and  Barthez,  discounte- 
nance it. 

It  is  well  to  bear  in  mind,  as  aiding  in  the  elucidation  of  this 
subject,  the  remark  made  by  Trousseau,  that  the  tooth  is  not  re- 
leased by  lancing  the  gum  over  the  advancing  crown.  The  gum 
is  not  rendered  tense  by  pressure  of  the  tooth,  as  many  seem  to 
think,  for,  if  so,  the  incision  would  not  remain  linear,  and  the  edges 
of  the  wound  would  not  unite,  as  they  ordinarily  do  by  first  inten- 
tion within  a  day  or  two.  This  speedy  healing  of  the  incision, 
unless  the  tooth  is  on  the  point  of  protruding,  is  an  important  fact, 


TREATMENT.  553 

for  it  shows  that  the  effect  of  the  scariiication  can  only  last  one  or 
two  days.  The  early  repair  of  the  dental  follicle  is  probably  con- 
servative so  far  as  the  development  of  the  tooth  is  concerned.  It 
may  help  us  to  understand  how  active,  how  powerful,  the  process 
of  absorption  is,  if  we  reflect  that  the  roots  of  the  deciduous  teeth 
are  more  or  less  absorbed  by  the  advancing  second  set,  without 
much  pain  or  suftering  from  the  pressure.  If  the  calcareous  par- 
ticles of  the  teeth  are  so  readily  absorbed,  what  is  the  foundation 
for  the  belief  that  the  fleshy  substance  of  the  gum  is  absorbed  with 
such  difliculty  ?  Too  much  importance  has  evidently  been  attached 
to  the  supposed  tension  and  resistance  of  the  gum  in  the  process 
of  dentition. 

Follicles  in  the  period  of  development  are  especially  liable  to 
inflammation.  We  see  this  in  the  follicular  stomatitis  and  enteri- 
tis, so  common  when  the  buccal  and  intestinal  follicles  are  in  the 
state  of  most  rapid  growth.  Does  not  this  law  in  reference  to  the 
follicles  hold  true  of  those  by  which  the  teeth  are  formed,  so  that 
the  period  of  their  enlargement  and  greatest  activity,  which  corre- 
sponds with  the  growth  and  protrusion  of  the  teeth,  is  also  the 
period  when  they  are  most  liable  to  congestion  and  inflammation  ? 
This  flict  aifords  a  better  explanation  of  the  frequency  of  the  so- 
called  laborious  or  difficult  dentition  than  that  it  is  due  to  the 
resistance  which  dental  evolution  encounters  from  the  gums. 

If  there  are  no  symptoms  except  such  as  occur  directly  from  the 
swelling  and  congestion  of  the  gum,  the  lancet  should  seldom  be 
used.  The  pathological  state  of  the  gum  which  would,  without 
doubt,  require  its  use,  is  an  abscess  over  the  tooth.  As  to  symp- 
toms which  are  general  or  referable  to  other  organs,  as  fever  and 
diarrhcea,  the  lancet  should  not  be  used  if  the  symptoms  can  be 
controlled  by  other  safe  measures.  All  co-operating  causes  should 
first  be  removed,  when  in  a  large  proportion  of  cases  the  patient 
will  experience  such  reliSf  that  scarification  can  be  deferred. 

If  the  state  of  the  infant  is  such  that  life  is  in  danger,  as  in 
convulsions,  or  there  is  danger  that  the  infant  will  be  permanently 
injured  or  disabled,  as  by  paralysis,  every  measure  which  can 
possibly  give  relief  should  be  employed  without  delay.  In  these 
dangerous  nervous  afl'ections,  therefore,  the  gums  if  swollen  should 
be  lanced.  I  know  no  accidents  of  dentition  which  require  prompt 
scarification  except  suppurative  inflammation  of  the  gums,  convul- 
sions, and  paralysis.  In  other  cases  the  operation  may  be  safely 
postponed  till  other  measures  have  been  employed. 


55i  DENTITION. 

Second  Dentition. 

The  fact  is  well  established,  though  often  overlooked  in  prac- 
tice, that  second  dentition  occasionally  deranges  the  functions  of 
organs,  and  gives  rise  to  pathological  symptoms.  Rilliet  and 
Barthez  mention  particularly  neuralgic  pains,  rebellious  cough, 
and  diarrhoea,  as  effects  which  they  have  observed.  Rilliet  re- 
lates the  case  of  a  girl  eleven  years  old,  who  had  a  very  obstinate 
and  protracted  cough,  the  paroxysms  lasting  often  half  an  hour 
to  an  hour.  This  cough  immediately  and  permanently  disappeared 
when  the  molars  pierced  the  gums. 

Dr.  James  Jackson,  in  his  Letters  to  a  Young  Physician^  says: 
"I  have  seen  persons  between  twenty  and  thirty  years  of  age 
much  affected  by  a  ivisdom  tooth  not  yet  protruded,  and  distinctly 
relieved  by  cutting  the  gum.  But  I  think  the  most  common 
period  of  suffering  from  the  second  dentition  is  from  the  tenth 
to  the  thirteenth  year.  The  most  characteristic  affections  are 
wasting  of  flesh  and  nervous  diseases.  The  boy  loses  his  comeli- 
ness, and  his  complexion  is  less  clear,  while  emaciation  takes  place 
in  every  part,  though  mostly,  perhaps,  in  the  face.  The  nervous 
symptoms  are  various,  but  the  most  common  are  a  change  in  the 
temper  and  a  loss  of  spirits.  "With  these  there  is  some  loss  of 
strength.  The  patient  is  unwilling  to  engage  in  play,  and  soon 
becomes  tired  when  he  does  do  it.  Among  the  distinct  symptoms 
which  are  not  uncommon,  I  may  mention  pain  in  the  head  and  in 
the  eyes.  The  headache  is  not  commonly  severe,  but  it  is  such  as 
inclines  the  patient  to  keep  still.  The  eyes  are  not  only  painful, 
but  are  often  aft'ected  with  the  morbid  sensibility  to  which  these 
organs  are  subject.  I  have  known  boys  truly  anxious  to  pursue 
their  studies  obliged  to  give  them  up  on  this  account ;  and  these, 
not  having  the  disposition  to  play,  will  of  choice  pass  the  day  with 
their  mothers,  and  increase  their  troubles  by  the  want  of  air  and 
exercise.  Nervous  affections  of  a  more  severe  character  are  some- 
times manifested." 

Whether  the  symptoms  which  have  been  attributed  to  second 
dentition  have  always  been  due  to  this  cause,  is  questionable. 
Practically,  however,  it  matters  little,  whether  we  recognize 
dentition  as  the  cause,  or  assign  something  else.  Hygienic  and 
medicinal  measures  to  improve  the  general  health  will  usually 
suffice  to  relieve  the  patient.  I  have  known  a  boy,  pallid  and  of 
nervous  temperament,  about  seven  years  old,  recover  immediately 
from  a  cough  which  had  lasted  for  several  weeks,  by  taking  three 


PHARYNGITIS — ANATOMICAL    CHARACTERS.  555 

times  daily  a  mixture  of  iron  and  nitric  acid.  Many  do  well 
without  medicine,  simply  by  hygienic  measures.  Dr.  Jackson 
says,  "  The  remedies  which  I  have  found  most  useful  are  as 
follows :  First,  a  relief  from  study  or  from  regular  tasks,  yet  using 
books  so  far  as  they  afford  agreeable  occupation  or  amusement. 
Second,  exercise  in  the  open  air,  preferring  the  mode  most  agree- 
able to  the  patient,  and  in  more  grave  cases  the  removal  from  town 
to  country." 


CHAPTER   V. 

SIMPLE  PHARYNGITIS,  PERI-PHARYNGEAL  ABSCESS, 

OESOPHAGITIS. 

Children  of  all  ages  are  liable  to  inflammation  of  the  pharynx. 
In  its  mildest  form  it  often,  doubtless,  escapes  detection  in  the 
young  infant.  In  older  patients  it  is  revealed  by  pain  in  swallow- 
ing solid  food,  and  more  or  less  tumefaction  below  the  ears 
apparent  to  the  sight.  It  is  said  to  be  less  frequent  in  infancy 
than  in  childhood.  In  the  adult,  and  in  children  over  the  age  of 
four  or  five  years,  inflammation  of  the  pharyngeal  surface  is  often 
confined  to  the  portion  of  membrane  which  covers  or  immediately 
surrounds  the  tonsils.  It  occurs  in  connection  with  inflammation 
of  these  glands.  But  in  infancy  and  early  childhood  this  limita- 
tion is  comparatively  rare.  Inflammation  of  the  throat  at  this  age 
is  ordinarily  a  general  pharyngitis,  the  tonsils  participating  in  the 
morbid  state. 

Pharyngitis  is  primary  or  secondary.  The  secondary  form 
occurs  in  measles,  scarlet  fever,  bronchitis,  croup,  pneumonitis, 
and  occasionally  in  other  afifections.  As  these  diseases  are  com- 
mon, physicians  are  oftener  called  to  treat  patients  who  have  the 
secondary  form  than  the  primary.  Rilliet  and  Barthez  met  eighty- 
three  secondary  to  sixteen  primary. 

Anatomical  Characters. — The  pathological  anatomy  of  pha- 
ryngitis is  ascertained  by  depressing  the  tongue  and  inspecting 
the  fauces.  The  membrane  lining  the  fauces  is  seen  to  be  redder 
than  in  health,  and  presenting  a  more  or  less  swollen  appearance, 
according  to  the  intensity  of  the  inflammation.  In  idiopathic 
pharyngitis,  the  fauces  commonly  have  a  bright  red  hue,  almost 
like  that  of  arterial  blood.     If,  on  the  other  hand,  the  inflamma- 


556  SIMPLE    PHARYNGITIS. 

tion  occurs  in  connection  witli  a  constitutional  afi'ection,  the  hue 
is  apt  to  be  darker.  In  grave  cases  of  scarlet  fever  or  measles,  it 
IS  sometimes  even  livid,  indicating  a  vitiated  state  of  the  blood,  a 
condition  of  real  danger.  The  tonsils  are  tumefied  so  as  to  pro- 
ject, though  not  to  the  extent  which  we  often  observe  in  the  adult. 
They  are  also  less  firm  than  in  the  normal  state.  The  follicles  of 
the  throat  are  enlarged  and  active,  pouring  out  a  muco-purulent 
secretion.  This  is  sometimes  seen  in  a  layer  over  the  tonsil  or  the 
posterior  portion  of  the  fauces.  In  a  case  of  primary  pharyngitis 
examined  after  death  by  Rilliet  and  Barthcz,  the  tonsils  were 
softened,  infiltrated  with  pus,  and  sliglitly  enlarged.  A  layer  of 
bloody  mucus  lay  on  the  pharynx,  and  the  pharyngeal  surface  was 
dark  red,  thickened  and  granular.  The  submaxillary  glands  were 
also  swollen  and  somewhat  softened. 

If  the  inflammation  is  intense,  the  deep-seated  portion  of  the 
tonsil  becomes  involved,  and  even  sometimes  the  adjacent  con- 
nective tissue.  In  most  cases,  by  applying  the  finger  in  the  hollow 
below  the  ears,  the  tonsil  can  be  felt.  In  severe  cases,  also,  the 
submaxillary  glands  are  tumefied. 

Causes. — The  usual  cause  of  primary  or  idiopathic  pharyngitis 
is  exposure  to  cold.  It  also  occasionally  occurs  from  the  use  of 
drinks  too  hot  or  containing  some  irritating  substance.  I  have 
met  it  in  the  most  intense  form  caused  by  swallowing  boiling 
water,  and,  in  one  case,  from  acetic  acid  taken  through  mistake. 
When  it  occurs  from  the  eruptive  fevers,  it  is  part  of  a  more 
extensive  mucous  phlegmasia,  although  the  inflammation  is  often, 
as  in  scarlet  fever,  more  intense  in  the  pharynx  than  elsewhere. 

Symptoms. — Tenderness  of  the  pharynx,  and  pain  on  swallowing, 
announce  pharyngitis.  These  symptoms  are  not  so  readily  detected 
in  infancy  as  in  childhood.  They  are  not  always  proportionate  to 
the  intensity  of  the  inflammation.  The  tongue  is  slightly  furred ; 
there  is  thirst,  and  the  appetite  is  more  or  less  impaired.  The 
breath  is  foul,  but  not  fetid;  the  respiration  is  normal,  or  but 
slightly  accelerated ;  cough  is  sometimes  present,  sometimes  absent. 
When  present,  it  is  due  to  extension  of  inflammation  to  the  upper 
part  of  the  larynx,  or  to  the  collection  of  mucus  around  the  aper- 
ture of  the  glottis. 

When  the  tonsils  are  considerably  enlarged,  and  the  adjacent 
parts  much  swollen,  the  voice  is  sometimes  much  altered,  present- 
ing a  nasal  character.  The  pulse  in  pharyngitis  is  accelerated, 
and  the  temperature  of  the  surface  elevated  according  to  the 
severity  of  the  inflammation. 


PROGNOSIS — DIAGNOSIS — TREATMENT.  557 

Prognosis. — In  mild  cases  of  pharyngitis  convalescence  com- 
mences within  a  Aveek.  If  the  inflammation  is  dependent  on  a 
constitutional  affection,  it  may  continue  a  much  longer  time, 
especially  if  the  glands  of  the  neck  and  the  connective  tissue  are 
much  involved.  The  prognosis  of  secondary  pharyngitis  is  less 
favorable  than  that  of  the  primary  form.  In  fatal  cases  there  is 
usually  a  vitiated  state  of  the  blood,  either  from  the  coexisting 
constitutional  disease,  or  from  previous  cachexia.  The  younger 
the  child,  also,  the  less  favorable  the  prognosis. 

Pharyngitis  may,  however,  become  dangerous  from  complica- 
tions to  which  it  gives  rise.  The  proximity  of  the  inflammation  to 
the  brain,  or  its  eflfect  upon  the  cerebro-spinal  axis  through  the 
medium  of  the  nerves,  sometimes  gives  rise  to  clonic  convulsions. 
In  a  recent  case  of  primary  pharyngitis  in  my  practice,  repeated 
and  violent  convulsions  occurred  in  an  infant,  about  one  year  old, 
from  this  cause.  They  commenced  at  the  inception  of  the  inflam- 
mation, and  constituted  the  only  real  danger.  Pharyngitis  may 
interfere  materially  with  nutrition  in  consequence  of  the  dysj)ha- 
gia,  but  in  most  cases  of  primary  pharyngitis  this  symptom  does 
not  continue  sufliciently  long  to  endanger  the  life  of  the  patient. 
In  grave  constitutional  aftections,  as  scarlet  fever,  the  difiiculty  of 
swallowing,  and  the  consequent  innutrition,  augment  the  danger. 
As  regards,  therefore,  the  prognosis  in  simple  pharyngitis,  whether 
primary  or  secondary,  it  may  be  stated  as  a  rule,  that  it  is  not,  jper 
se,  a  fatal  disease,  but  is  only  so  from  complications,  or  from 
aggravating  the  primary  affection  with  which  it  is  associated. 

Diagnosis. — This  is  never  difiicult  provided  attention  is  directed 
to  the  throat ;  but  the  physician  often  fails  to  discover  it  at  his  first 
visit,  from  neglecting  to  examine  this  part.  In  many  cases  the 
local  symptoms  are  not  well-marked,  and  in  the  absence  of  these 
the  febrile  reaction  may  at  first  be  referred  to  some  other  cause 
than  the  true  one.  Inspection  not  only  reveals  the  presence  of 
inflammation,  but  enables  us  to  determine  whether  it  is  simple 
pharyngitis,  or  diphtheritic,  or  ulcerative.  In  some  instances, 
simple  pharyngitis  resembles  diphtheritic,  from  the  presence  of 
confervoid  growths  upon  the  inflamed  surface,  usually  the  lepothrix 
buccalis.  The  differential  diagnosis  is  based  on  the  easy  removal 
and  soft  pultaceous  character  of  the  confervee,  and  the  appearance 
under  the  microscope. 

Treatment. — Mild  cases  of  simple  pharyngitis  require  little 
treatment.  With  moderate  counter-irritation  over  the  throat,  and 
the  use  of  laxative  medicines,  the  inflammation  soon   subsides. 


558  SIMPLE    PHARYNGITIS. 

The  linimentum  camphorse  may  be  occasionally  rubbed  over  the 
throat,  and  retained  upon  it  by  flannel.  The  effect  is  increased 
by  the  application,  once  or  twice  daily,  of  mustard  or  tincture  of 
iodine,  or  by  adding  to  the  liniment  a  little  volatile  liniment  or 
turpentine.  Mucilaginous  and  refrigerant  drinks,  with  a  light 
diet,  suffice  to  complete  the  cure. 

In  the  severe  form  of  idiopathic  pharyngitis  more  active  mea- 
sures are  required.  The  bowels  should  be  freely  opened,  warm 
mustard  pediluvia  occasionally  employed,  and  the  head  be  kept 
cool.  If  the  patient  is  robust,  as  in  the  first  stages  of  the  disease, 
and  there  is  threatening  of  cerebral  complication,  it  is  proper  to 
apply  one  or  more  leeches  to  the  temples  or  neck ;  but  cases  re- 
quiring such  depletion  are  exceptional. 

Diaphoretics  and  sometimes  cardiac  sedatives  are  indicated,  such 
as  liquor  ammonise  acetati's,  spiritus  fetheris  nitrosi,  ipecacuanha, 
tartrate  of  antimony  and  potassa,  aconite,  and  veratrum  viride. 
Medicines  of  this  kind  may  be  variously  combined  according  to 
the  age  and  condition  of  the  patient,  and  the  severity  of  the  dis- 
ease.    Saline  laxatives  are  also  in  some  cases  useful. 

As  the  symptoms  abate,  the  intervals  between  the  doses  may  be 
increased.  In  those  cases  of  severe  idiopathic  pharyngitis  attended 
by  pain  in  deglutition,  moderate  but  constant  counter-irritation 
should  be  employed  over  the  seat  of  inflammation.  An  excellent 
application,  and  one  much  used  in  families,  is  a  slice  of  fat  salt 
pork,  cut  as  thin  as  possible,  stitched  on  a  single  thickness  of  muslin, 
and  applied  from  ear  to  ear.  It  is  better,  usually,  to  sprinkle  more 
salt  upon  it,  and  sometimes  powdered  camphor. 

In  cases  of  much  tenderness  and  dysphagia  great  relief  is  often 
obtained  by  emollient  poultices  applied  over  the  throat.  Mustard 
or  iodine  may  also  be  occasionally  employed  in  addition  if  there  is 
not  already  sufficient  counter-irritation. 

Topical  treatment  of  the  pharynx  is  recommended  by  most 
authors.  Rilliet  and  Barthez  use  for  this  purpose  nitrate  of  silver 
or  powdered  alum.  The  former  has  been  most  employed  by  phy- 
sicians. It  may  be  applied  in  the  proportion  of  ten  grains  to  the 
ounce,  two  or  three  times  daily.  I  have  commonly  prescribed  the 
liquor  ferri  subsulphatis  mixed  with  three  or  four  times  its  quantity 
of  glycerine,  for  application  to  the  inflamed  part,  and  with  a  good 
result. 

Gargles,  which  we  so  often  prescribe  in  the  pharyngitis  of 
adults,  cannot  be  satisfactorily  employed  in  infancy  and  early 
childhood. 


PERI-PnARYNGEAL    ABSCESS.  559 

The  treatment  of  secondary  pharyngitis  will  be  described  in 
connection  with  the  treatment  of  the  diseases  which  it  complicates. 
Suffice  it  here  to  say  that  this  form  of  inflammation  must  not  be 
treated  by  those  depressing  remedies  which  are  useful  in  certain 
cases  of  idiopathic  pharyngitis. 

Pseudo-membranous  pharyngitis,  or  diphtheria,  being  a  constitu- 
tional disease,  has  been  described  elsewhere. 

Peri-Pharyngeal  Abscess. 

Every  practitioner  should  bear  in  mind  the  fact  that  an  abscess 
occasionally  forms  between  the  pharynx  and  vertebral  column 
(retro-pharyngeal),  or  upon  the  sides  of  the  pharynx  in  the  sub- 
mucous connective  tissue.  This  constitutes  a  disease  which  is  apt 
to  be  fatal,  but  which  can  ordinarily  be  promptly  relieved  by  the 
surgeon. 

Yet,  if  we  look  over  the  records  of  peri-pharyngeal  abscess,  we 
shall  see  that  in  a  large  proportion  of  published  cases,  the  disease 
was  supposed  to  be  something  else,  and  so  treated  until  its  nature 
was  revealed  by  post-mortem  examination.  The  most  complete 
monograph  on  this  disease  with  which  I  am  acquainted  was  pub- 
lished by  Dr.  Allin,  of  this  city,  in  the  N.  Y.  Journ.  of  Meek  for 
'Nov.  1851,  under  the  title  of  retro-pharyngeal  abscess.  To  this 
paper  I  am  largely  indebted  for  facts. 

Age — Cause. — This  disease  may  occur  at  any  age ;  but  it  is 
most  common  in  infancy  and  childhood.  It  is  more  frequent  in 
the  first  year  of  life  than  at  any  other  period.  Of  the  cases  collated 
by  Dr.  Allin,  in  which  the  age  is  stated,  twenty  were  under  ten 
years,  while  the  number  for  all  other  ages  was  twenty-one.  This 
disease  arises  in  some  patients  from  caries  of  the  vertebral  column, 
and,  in  others,  from  inflammation  commencing  with  the  mucous 
membrane  of  the  pharynx,  and  extending  to  the  submucous  con- 
nective tissue.  Whichever  the  cause,  there  is  usually  a  scrofulous 
or  reduced  state  of  system. 

Writers  describe  two  kinds  of  peri-pharyngeal  abscess,  the  pri- 
mary and  secondary.  This  distinction  is  based  on  the  fact, 
whether  or  not  the  inflammation  which  leads  to  the  abscess  is  de- 
pendent on  an  antecedent  pathological  state. 

In  the  primary  form  the  cause  is  usually  atmospheric,  or  it  is 
some  irritating  substance  which  has  been  swallowed,  and  which, 
lodging  in  the  pharnyx,  produces  pharyngitis. 

The  cause  is  mentioned  in  twenty  cases  of  the  primary  form, 


560  PEKI-PHARYNGEAL    ABSCESS. 

collated  by  Dr.  Allin,  as  follows:  exposure  to  cold,  ten  cases; 
lodgement  of  bone  in  pharynx,  eight  cases ;  blow  with  a  fencing 
foil,  one  case.  In  the  last  case,  the  button  of  a  fencing  foil  passed 
through  the  right  nostril  into  the  pharynx. 

The  secondary  form  occasionally  occurs  after  measles  and  scarlet 
fever.  The  inflammation  of  the  pharynx,  common  in  those  dis- 
eases, extends  to  the  subjacent  connective  tissue,  and,  aided  by  the 
dyscrasia  of  the  patient,  becomes  suppurative.  Such  cases  have 
been  observed  by  Rilliet  and  Barthez.  The  most  common  cause 
of  the  secondary  form  is,  however,  caries  of  the  vertebral  column. 

When  thus  occurring  it  is  similar,  both  as  regards  cause  and 
nature,  to  lumbar  abscess.  It  would  follow  the  same  chronic 
course,  and  would  properly  be  described  in  connection  with  it, 
were  it  not  for  its  proximity  to  the  air  passages,  which  renders 
the  disease  so  rapid  and  fatal.  In  a  few  recorded  cases  the  abscess 
has  been  a  sequel  of  erysipelas.  It  is  believed  by  some  that  when 
it  thus  occurs  there  is  retrocession  of  the  erysipelatous  eruption. 
In  nineteen  cases  of  secondary  abscess  in  Dr.  Allin's  collection, 
the  cause  is  assigned  as  follows :  erysipelas  of  face,  two ;  inflamma- 
tion following  a  fall  upon  the  inferior  maxilla,  one ;  after  cerebri- 
tis,  one ;  syphilis,  four ;  caries  of  the  cervical  vertebra,  six  ;  scrofula, 
five; 

The  proximate  cause  of  peri-pharyngeal  abscess  is  believed  by 
Mr.  Fleming  {Dublin  Journ.  of  lied.  Sci.  vol.  xvii.)  to  be  in  some 
instances  inflammation  of  small  lymphatic  glands  lying  in  the  con- 
nective tissue  external  to  the  pharynx.  After  remarking  that  two 
cases  which  he  reports  lend  confirmation  to  this  view,  he  con- 
tinues :  "  That  those  glands  are  only  occasionally  found  in  this 
situation,  I  admit,  and  hence,  probably,  the  rare  occurrence  of  this 
particular  form  of  disease,  but  that  they  exist  more  frequently 
than  is  generally  imagined,  I  am  equally  certain."  Prof.  Geo.  T. 
Elliot  relates  a  case  {Obstet.  Clinic,  N.  F.,  Appleton  &  Co.,  1868)  in 
which  peri-pharyngeal  abscess  immediately  followed  and  was  appa- 
rently due  to  parotiditis.  The  patient  was  a  boy  seven  months 
old. 

In  rare  instances  the  abscess,  or  the  local  disease  which  leads  to 
it,  appears  to  exist  from  birth.  Thus,  Dr.  E.  0.  Ilocken  relates,  in 
the  Prov.  Med.  and  Surg.  Journ.,  1842,  the  history  of  an  infant 
who  died  at  the  age  of  nine  weeks.  It  had  always,  when  taking 
the  breast,  thrown  back  its  head  as  if  nearly  suffocated.  The 
walls  of  the  abscess  were  thick  and  firm,  described  by  the  writer 


ANATOMICAL    CHARACTERS  —  SYMPTOMS.  501 

as  cartilaginous.  Occasionally  there  is  no  apparent  cause  of  the 
abscess.     We  must  then  attribute  it  to  some  unknown  dyscrasia. 

Anatomical  Characters. — The  seat  of  the  abscess  is  not  the 
same  in  all  cases.  The  swelling  can  ordinarily  be  seen  on  exami- 
ning the  fauces,  but  occasionally  it  is  so  low  as  to  be  really  peri- 
ocsophageal,  and  therefore  invisible.  The  size  of  the  abscess  varies  ; 
sometimes  it  is  large,  pressing  inward  the  wall  of  the  pharynx 
even  against  the  velum  palati  and  into  the  posterior  nares,  if  the 
abscess  have  a  high  location,  or,  if  lower,  against  the  larynx,  so 
as  to  embarrass  respiration.  Sometimes  the  abscess  is  so  large  or 
has  such  lateral  extension  that  there  is  external  swelling  along  the 
side  of  the  neck.  In  a  few  cases  on  record  the  pus,  instead  of 
being  discharged  into  the  pharynx,  made  its  way  down  the  neck 
between  the  muscles  and  the  connective  tissue  to  the  pleural  cavity, 
which  it  entered,  producing  fatal  pleuritis. 

The  walls  of  the  abscess  have  been  found  in  a  different  state  in 
different  cases.  Sometimes  the  sac,  at  the  projecting  point,  is  so 
thin  that  it  seems  as  if  there  might  have  been  a  spontaneous  cure, 
could  life  have  been  preserved  a  few  hours  longer.  In  other  cases 
the  sac  is  so  thick  and  firm  that  its  rupture,  for  many  days,  would 
be  impossible. 

Symptoms. — The  precursory  symptoms  differ  in  different  cases, 
according  to  the  nature  of  the  cause,  whether  it  be  pharyngitis, 
glandular  inflammation,  or  vertebral  caries.  If  the  abscess  proceed 
from  caries,  it  is  preceded  by  deep-seated  and  protracted  pain, 
greatly  increased  by  movements  of  the  head. 

The  patient  with  this  disease  is  restless,  his  mouth  hot  and  dry ; 
tongue  furred;  deglutition  more  or  less  diflicult.  Sometimes  after 
suppuration  has  occurred  there  are  alternations  of  heat  and  chills. 
The  -symptoms  indicate  approximately  the  seat  of  the  inflamma- 
tion, but  on  examination  we  do  not  find  that  des-ree  of  redness 

7  Cj 

and  swelling  of  the  mucous  surface  which  we  had  been  led  to 
expect.  The  tissues  which  are  chiefly  involved  in  the  inflamma- 
tion, being  submucous,  are  hidden  from  view.  We  observe  redness 
of  the  pharynx,  but  it  is  disproportionate  to  the  intensity  of  the 
symptoms.  Sometimes  there  is  a  sensation  of  chilliness  through 
the  entire  period  of  the  abscess,  though  greater  at  one  time  than 
at  another,  and  occasionally  convulsions  occur,  especially  in  young 
infants.  In  ordinary  cases  the  embarrassment  of  respiration  is 
one  of  the  first  and  most  conspicuous  of  the  symptoms,  and  it  is 
the  cause  of  the  chief  dangeiv  It  becomes  more  and  more  marked 
as  the  abscess  increases.  It  is  noticed  both  during  inspiration  and 
36 


562  PERI-FHARYNGEAL    ABSCESS. 

expiration.  The  dysphagia  also  increases,  sometimes  to  such  a 
degree  that  drinks  are  taken  with  difficulty,  and  solid  food  refused. 
The  respiratory  symptoms  bear  considerable  resemblance  to  those 
in  protracted  laryngitis,  for  which  this  disease  has  been  mistaken. 
While  the  respiration  becomes  impeded  or  whistling,  the  voice  is 
also  feeble  or  indistinct,  from  the  pressure  of  the  tumor. 

But  the  symptoms  described  above  are  not  all  present  in  every 
case.  They  vary  according  to  the  size  and  location  of  the  abscess, 
whether  it  be  high  or  low,  posterior  or  lateral.  I  have  met  the  dis- 
ease in  a  child  old  enough  to  express  its  subjective  symptoms,  in 
whom  there  was  little  or  no  dysphagia,  and  others  report  similar 
cases.  "When  the  tumor  has  attained  such  a  size  as  to  produce  well- 
marked  symptoms  and  jeopardize  the  life  of  the  patient,  it,  or  a 
part  of  it,  can  ordinarily  be  seen  on  depressing  the  tongue,  but 
usually  its  location  and  condition  can  be  better  ascertained  by 
exploration  with  the  linger.  The  dyspnoea  increases  as  the  abscess 
enlarges,  and,  after  a  time,  unless  it  bursts  spontaneously  or  is 
opened  by  the  surgeon,  imperfect  oxygenation  of  the  blood  results. 
In  some  patients  paroxysms  of  dyspnoea  occur,  so  as  to  threaten 
immediate  suffocation;  coughing  or  attempts  to  swallow  induce 
these  paroxysms,  and  the  patient  is  forced  to  remain  in  an  erect  or 
semi-erect  posture.  The  tongue  is  protruded,  the  head  thrown 
back,  the  pulse  is  frequent  and  rapid,  the  limbs  become  livid  and 
cool,  and  linally  death  occurs  from  apncea.  Occasionall}^,  when 
death  seems  inevitable,  the  abscess  gives  way  by  the  struggles  of 
the  child,  and  the  patient  is  restored  to  health.  In  rare  cases  the 
result  is  different.  The  trachea  and  bronchial  tubes  are  deluged 
by  the  purulent  discharge,  and  immediate  suffocation  occurs.  The 
following  was  an  example:  In  May,  1871,  a  boy  two  years  and 
five  months  old  was  brought  to  the  Clinic  at  Bellevue,  who  had 
had  the  symptoms  of  an  abscess  for  three  months.  The  head  was 
carried  one  side,  its  rotation  caused  pain,  and  a  laryngeal  rule 
accompanied  respiration.  The  uj)per  part  of  the  tumor  could  be 
detected  by  the  finger,  but,  on  account  of  its  low  location,  it  was 
imix)ssible  to  open  it  with  the  bistoury.  The  temperature  was 
103°,  pulse  156.  The  case  was  kept  under  observation,  but  in  a 
few  days  the  dyspnoea  suddenly  became  so  urgent  that  death  was 
imminent,  when  the  attending  physician  of  the  class,  Dr.  Swezey, 
broke  the  abscess  with  his  finger,  and  pus  was  ejected  on  the  floor; 
death,  however,  occurred  almost  immediately. 

A  correct  appreciation  of  the  symptoms  and  the  nature  of  peri- 
pharyngeal abscess  will  be  best  obtained  by  relating  a  case.     I 


SYMPTOMS.  563 

select  the  following  from  the  Transactions  of  the  London  Patholor/ical 
Society,  October  20th,  184G:— 

A  female  infiint  died  at  the  age  of  seven  months,  having  had 
difficult  breathing  three  weeks,  and  extreme  dyspnoea  during  the 
last  days  of  life.  The  dyspnoea  was  constant,  and  was  aggravated 
by  mental  excitement,  by  movements  of  the  body,  and  by  exposure 
to  cold.  During  the  paroxj'sms,  a  peculiar,  croupy  sound  accom- 
panied inspiration.  There  was  no  dysphagia  through  the  entire 
sickness,  and  death  occurred  from  apncea. 

The  sac  of  the  abscess  was  of  the  size  of  a  pigeon's  egg,  and 
was  situated  between  the  upper  cervical  vertebrte  and  the  back 
of  the  pharynx.  The  abscess  was  flattened  in  front,  so  as  not  to 
cause  any  material  prominence  of  the  wall  of  the  pharynx.  From 
the  sac  a  second  small  cyst  extended  forward,  forming  a  nipple- 
like swelling  in  the  pharynx,  which  completely  closed  the  orifice 
of  the  glottis.  Its  aperture  of  communication  with  the  body  of 
the  abscess  admitted  the  point  of  the  little  finger,  and  the  whole 
swelling  was  freely  movable  and  perfectly  translucent  at  its  ex- 
tremities and  sides.  The  abscess  might  have  been  easily  punctured, 
with  probably  the  preservation  of  life. 

The  duration  of  this  disease  is  very  different,  according  to  the 
severity  of  the  inflammation,  the  rapidity  with  which  the  abscess 
enlarges,  and  the  direction  which  it  points.  A  lateral  or  down- 
ward extension  is  not  so  immediately  dangerous  to  life  as  the 
anterior. 

The  time  when  the  abscess  begins  to  form  cannot  be  precisely 
ascertained,  and  most  writers,  in  determining  the  duration  of  the 
disease,  compute  from  the  first  appearance  of  symptoms  which 
are  referable  to  the  pharynx.  Dr.  J.  Bryne  relates,  in  the  Amer. 
Journ.  of  Med.  Sci.,  1838,  a  fatal  case  in  which  the  disease  had 
apparently  continued  only  about  one  week.  The  patient  was  an 
infant  one  year  old,  and  died  of  apnoea.  The  abscess  was  large, 
extending  from  the  base  of  the  skull  to  the  thorax,  and  pressing 
both  on  the  larynx  and  trachea.  M.  Besserer  [Archiv.  Gen.  de 
3Ied.,  1840)  gives  the  history  of  an  infant  four  months  old,  who 
died  in  the  same  way  after  thirteen  days.  An  infant  nine  months 
old,  whose  case  was  published  by  Dr.  W.  C.  "Worthington,  in  the 
Prov.  Med.  and  Surg.  Journ.,  1842,  lived  nine  days.  The  abscess 
occurred  from  exposure  to  cold  ;  the  patient  was  treated  for  croup, 
and  died  from  suffocation.  The  anterior  wall  of  the  abscess  was 
very  thin.  Since  the  first  edition  of  this  book  was  published,  I 
have  met  three  patients  with  this  disease  in  whom  the  pus  was 


564:  PERI-PHARYNGEAL    ABSCESS. 

evacuated  when  the  dyspnoea  had  become  urgent.  In  two  the 
symptoms  indicated  a  continuance  of  the  disease  from  two  to  tour 
weeks,  and  in  the  third  case  four  months. 

When  the  abscess  grows  slowly,  and  presses  lightly  on  the  air- 
passages,  the  case  may  continue  for  months.  Such  a  one  was 
observed  by  Prof.  Willard  Parker  (Allin).  This  infant  was  one 
year  old ;  it  suffered  from  pharyngeal  symptoms  nine  months,  was 
treated  for  tonsillitis,  and  death  occurred  as  usual  from  apnoea. 
The  abscess  was  two  inches  long,  and  there  was  no  disease  of  the 
vertebrae.  The  same,  surgeon  saved  the  life  of  another  patient  four 
years  old,  in  whom  the  disease  was  chronic,  by  puncturing  the 
abscess;  and  Prof.  Post,  of  this  city,  also  treated  successfully  a 
case  which  had  continued  three  months.     (Allin.) 

Diagnosis. — The  diagnosis  of  this  disease  is  ordinarily  not 
difficult,  provided  the  physician  examine  carefully  and  bear  in 
mind  the  occasional  occurrence  of  such  an  abscess.  In  a  large 
proportion,  however,  of  the  recorded  fatal  cases,  the  true  nature 
of  the  disease  was  not  recognized  during  life.  Especially  is  the 
diagnosis  difficult  when  the  cerebro-sj^inal  system  is  early  impli- 
cated, and  symptoms  arise  which  divert  attention  from  the  throat 
to  the  brain. 

The  diseases  with  which  peri-pharyngeal  abscess  is  most  fre- 
quently confounded  are  laryngitis  and  simple  but  severe  pharyn- 
gitis. From  laryngitis,  for  which  it  has  been  most  frequently 
mistaken,  it  may  be  distinguished  by  the  dysphagia  and  by  the 
character  of  the  initial  symptoms.  In  laryngitis  there  is  usually 
the  peculiar  cough  from  the  first  or  very  early,  while  in  abscess 
there  is  a  period  of  several  days  or  even  weeks  before  respiration 
is  materially  affected. 

In  abscess  pressure  of  the  larynx  backward  is  badly  tolerated, 
greatly  increasing  the  dyspnoea,  while  in  pharyngitis  and  croup 
this  effect  is  not  so  marked.  In  abscess  the  horizontal  position 
aggravates  the  dyspnoea,  but  not  in  pharyngitis  and  croup.  The 
character  of  the  voice  will  also  aid  in  diao-nosticatino;  abscess 
from  laryngitis,  since  in  the  former  it  is  apt  to  be  nasal,  and  in 
the  latter  hoarse  or  whispering.  The  decisive  test  is  afforded  by 
inspection  and  digital  exploration.  The  tumor  is  seen,  or,  if 
situated  too  low  to  be  seen,  is  felt,  upon  the  walls  of  the  pharynx. 

If  the  symptoms  of  abscess  are  masked  by  those  arising  from 
the  cerebro-spinal  system,  as  by  convulsions,  the  priority  of  the 
pharyngeal  symptoms  will  serve  to  aid  in  determining  the  true 
disease. 


PROGNOSIS  —  TREATMENT.  565 

In  a  case  of  suspected  abscess  the  physician  should  not  only 
carefully  inspect  the  fauces,  but  should  employ  digital  examination. 
The  finger  will  sometimes  detect  fluctuation  when  no  evidence  of 
an  abscess  is  presented  to  the  eye.  Two  cases  observed  by  Prof. 
Elliot  {Obstet.  Clinic,  p.  420)  were  examples  in  point. 

Prognosis. — '"With  proper  treatment  the  result  is  usually  favora- 
ble, but,  if  the  disease  is  not  recognized,  the  majority  die.  In  Dr. 
Allin's  cases,  of  those  under  the  age  of  twelve  years  nine  died, 
while  ten  recovered  by  the  opening  of  the  abscess  by  the  lancet, 
trocar,  or  finger,  and  one  by  its  spontaneous  rupture. 

If  the  abscess  is  due  to  disease  of  the  spinal  column,  death  may 
occur  immediately  after  the  sac  is  opened,  the  caries  of  the  inter- 
vertebral cartilages  producing,  according  to  Dr.  Allin,  dislocation 
of  the  vertebrffi.  Death  may  also  occur,  though  rarely,  from  pleu- 
ritis,  in  consequence  of  the  bursting  of  the  abscess  into  the  pleural 
cavity.  Even  in  caries,  if  the  sac  is  properly  opened,  and  if  need 
be  reopened,  recovery  is  possible,  as  in  a  case  treated  by  Prof. 
Post. 

Treatment. — The  proper  treatment  of  peri-pharyngeal  abscess 
is  simple,  consisting  in  breaking  or  puncturing  the  sac  by  the  fin- 
ger, the  lancet,  bistoury,  or  pharyngotome.  Each  method  has 
been  successfull}'"  employed.  In  the  majority  of  cases  the  proper 
way  to  open  the  abscess  is  by  the  ordinary  curved  scalpel  or  bis- 
toury, which  should  be  covered  by  a  strip  of  adhesive  plaster  to 
within  a  half  inch  of  the  point.  If  the  abscess  is  post-pharyngeal, 
it  should  be  opened  in  the  median  line.  A  single  incision  suflices 
to  evacuate  the  pus.  If  the  abscess  points  or  is  elastic,  there  is 
little  danger  of  wounding  any  important  vessel  or  producing  dan- 
gerous hemorrhage  if  the  operation  is  properly  performed.  It  may 
be  necessary  to  open  the  abscess  more  than  once,  as  in  a  case  re- 
ported by  Dr.  Post,  and  another  which  I  saw  with  Dr.  Livingston 
of  this  city.  In  certain  cases,  w^hen  the  knife  can  not  be  readily 
employed,  the  abscess  may  be  opened  by  pressure  with  the  finger 
nail  or  the  edge  of  a  teaspoon. 

Patients  with  this  disease  ordinarily  require  constitutional  treat- 
ment, especially  the  use  of  tonics,  ferruginous  and  vegetable.  The 
citrate  of  iron  and  quinine,  the  citrate  of  iron  and  ammonia,  and 
in  strumous  cases  the  syrup  of  the  iodide  of  iron  with  cod-liver 
oil,  are  eligible  preparations.  Nutritious  diet  and  often  alcoholic 
stimulants  are  required. 


566  (ESOFHAGITIS. 

Qjsophagitis. 

Disease  of  the  cesopliagus  in  infancy  and  childhood  is  compara- 
tively rare,  inflammation  being  the  most  frequent  affection  of  this 
portion  of  the  digestive  tube  in  these  periods,  and,  indeed,  the  only 
one  which  claims  attention.  It  is  most  common  in  infants  under 
the  age  of  three  or  four  months,  who  are  deprived  of  the  breast 
milk,  and  are  given  a  diet  which  is  with  difficulty  digested,  and 
perhaps  taken  too  hot  or  too  cold.  It  is,  therefore,  most  frequent 
in  foundling  hospitals.  I  have  frequently  observed  it  in  the  In- 
fant's Hospital,  and  the  ISTursery  and  Child's  Hospital,  of  this  city, 
chiefly  at  the  autopsies  of  bottle-fed  infants,  under  the  age  of  six 
months,  whose  symptoms  had  indicated  disease  or  derangement  of 
the  digestive  function.  Many  of  them  had  diarrhoea,  and  died  in 
a  state  of  emaciation.  CEsophagitis  in  these  cases  was  associated 
with  simple  or  gangrenous  stomatitis,  thrush,  or  with  gastritis  or 
entero-colitis.  Sometimes  all  these  inflammations  coexisted.  In  a 
few  cases  the  confervoid  growth  of  thrush  had  extended  from  the 
mouth  to  the  oesophagus.  It  occurred  in  small  hemispherical 
masses,  scarcely  as  large  as  a  pin's  head.  Swallowing  corrosive  or 
strongly  irritating  substances,  as  the  acids  or  alkalies,  is  an  occa- 
sional cause  of  oesophagitis,  the  irritant  at  the  same  time  producing 
stomatitis  and  gastritis. 

Anatomical  Characters. — The  inflamed  surface  sometimes 
presents  a  uniformly  injected  appearance.  Usually,  however, 
there  is  greater  intensity  of  inflammation  in  streaks  or  patches 
than  over  the  surface  generally.  I  have  frequently  observed  at 
autopsies  a  greater  degree  of  inflammation  in  the  lower  than  upper 
half  of  the  oesophagus,  even  when  the  infant  had  stomatitis  at  the 
time  of  death. 

CEsophagitis  occurring  from  faulty  regimen  or  anti-hygienic  con- 
ditions is  not  accompanied  by  as  much  thickening  of  the  walls  of 
the  tube  as  often  occurs  in  some  other  portions  of  the  digestive 
canal,  as,  for  example,  in  the  colon.  In  diphtheritic  inflammation 
of  the  oesophagus  there  are  more  submucous  infiltration  and  thick- 
ening of  the  nmcous  membrane  than  in  simple  oesophagitis. 

Occasionally  ulcerations  of  the  oesophageal  mucous  membrane 
are  observed  in  the  lower  part  of  the  tube,  and  Billard  describes 
the  ulcerative  form  of  oesophagitis.  At  the  first  autopsies  at  which 
I  observed  these  ulcers,  I  supposed  that  they  were  pathological, 
and  indicated  a  severe  grade  of  inflammation ;  but  a  more  extended 
observation  has  convinced  me  that  they  are  usually  post-mortem. 


INDIGESTION.  567 

and  are  not  at  all  dependent  on  inflammation  of  the  ocsopliagus. 
The  solvent  power  of  the  gastric  juice  not  only  causes  ulceration 
in  the  stomach,  but  entering  the  oesophagus  may  and  not  infre- 
quently does  produce  a  solvent  action  on  the  mucous  tissue  there. 
At  the  meeting  of  the  London  Pathological  Society,  March  4th, 
1852,  Dr.  Graily  Hewitt  presented  a  specimen  in  wliich  the  gastric 
juice  had  not  only  eaten  entirely  through  the  coats  of  tlie  oesopha- 
gus an  inch  above  the  stomach,  but  had  even  attacked  the  left  lung. 
Over  the  age  of  six  months  inflammation  of  the  oesophagus  is  rare. 

The  symptoms  of  oesophagitis,  in  those  young  and  emaciated 
infants  in  whom  it  ordinarily  occurs,  are  not  well  pronounced.  If 
they  have  pain  in  deglutition,  or  tenderness  on  pressure  over  the 
oesophagus,  it  is  not  apparent.  ISTor  have  they  seemed  to  me  to 
vomit  oftener  than  other  infants  of  this  class  suffering  from  indi- 
gestion and  gastro-enteritis,  without  oesophagitis.  It  is,  therefore, 
difficult  to  diagnosticate  oesophagitis.  It  is,  according  to  my 
observation,  oftener  present  than  absent  in  spoon-fed  infants  of 
three  months  or  under  who  have  persistent  stomatitis  and  entero- 
colitis. 

Treatment. — In  the  oesophagitis  of  foundlings  and  ill-nourished 
infants,  which  arises,  as  has  been  stated,  from  faulty  regimen,  no 
treatment  is  required  apart  from  that  designed  to  relieve  the 
stomatitis  or  entero-colitis  with  which  it  exists.  Attention  must 
be  directed  mainly  to  the  diet  and  hygienic  management.  The 
remedial  measures  are  more  fully  detailed  in  our  remarks  on  entero- 
colitis. CEsophagitis  produced  by  swallowing  corrosive  or  highly 
irritating  substances  requires  the  same  treatment  as  in  the  adult, 
namely,  poultices,  demulcent  drinks,  perhaps  leeches,  etc. 


CHAPTER  VI. 

INDIGESTION,  CONGESTION  OF  STOMACH,  GASTRITIS,  FOLLICU- 
LAR GASTRITIS,  DIPHTHERITIC  GASTRITIS,  POST-MORTEM  DI- 
GESTION, SOFTENING. 

Indigestion  is  much  more  common  during  infancy  than  in  any 
other  period  of  life.  While  the  digestive  organs  in  the  adult 
easily  assimilate  a  great  variety  of  food,  it  is  necessary  for  the 
well-being  of  the  infant  that  its  diet  be  simple  and  carefully  pre- 


568  INDIGESTION. 

pared.     Departure  from  this  rule  leads  to  indigestion  and  ulterior 
diseases. 

After  the  age  of  two  years  a  mixed  diet  is  readily  assimilated, 
the  digestive  function  less  frequently  disordered,  and  indigestion 
presents  few  peculiarities  to  distinguish  it  from  that  of  the  adult. 

Indigestion  in  some  children  is  habitual;  in  others  the  digestive 
process  is  ordinarily  well  performed,  but,  from  some  temporary 
derangement  of  system  or  error  of  diet,  an  acute  attack  of  indiges- 
tion occurs.  Hence,  two  forms  of  this  ailment  may  be  described : 
first,  acute,  referring  to  temporary  attacks;  secondly,  chronic, 
referrinij  to  the  habitual  state. 

Causes. — The  causes  of  indigestion  are  twofold:  first,  the  con- 
condition  of  the  digestive  function  independently  of  the  aliment ; 
secondly,  the  unwholesome  or  improper  character  of  the  ingesta. 
Anything  which  lowers  the  vital  powers  may  be  a  predisposing 
cause  of  indigestion,  by  impairing  the  functions  of  some  of  the 
organs  which  assimilate  the  food.  Impure  air  and  personal 
uncleanliness,  protracted  hot  weather,  and  previous  disease,  are 
among  the  common  predisposing  causes.  The  strong  country 
child  can  thrive  upon  a  diet  which,  given  to  the  more  feeble  child 
of  the  city,  would  produce  deleterious  results.  During  the  sum- 
mer months  it  often  happens  that  an  infant  in  the  city  cannot 
digest  properly  any  food  given  to  it  except  the  mother's  milk; 
and  from  this  results  much  of  the  infantile  sickness  and  mortality 
which  make  this  season  of  the  year  so  much  dreaded  by  parents. 
There  is  a  natural  difference  in  children,  as  regards  liability  to 
disordered  digestion.  Some  do  well  upon  a  diet  which  given  to 
others  similarly  situated  occasions  vomiting,  gastralgia,  and  flatu- 
lence. 

In  the  majority  of  cases  of  indigestion,  however,  the  fault  does 
not  exist  in  the  child.  It  is  fed  too  often  or  irregularly,  or  upon 
a  diet  that  is  unwholesome  or  indigestible.  It  is  well  known  that 
the  milk  of  the  mother  or  the  wet-nurse  is  liable  to  changes 
which  render  it  for  the  time  unsuitable  for  the  infant.  Her  food 
may  be  of  such  a  quality,  or  her  mind  so  excited,  or  some  func- 
tion of  her  system  so  disordered,  as  to  effect  a  temporary  change 
in  the  constitution  of  the  milk.  The  occurrence  of  the  catamenia, 
or  of  gestation,  in  mothers  who  are  suckling,  not  infrequently  pro- 
duces this  unfavorable  result. 

Indigestion  is  most  common  in  those  infants  who,  deprived  of 
the  mother's  milk,  are  intrusted  to  wet-nurses,  or  fed  from  the 
bottle.     The  milk  of  the  wet-nurse,  from  not  agreeing  with  the 


SYMPTOMS.  5t)9 

age  of  the  infant,  from  irregularity  in  her  mode  of  life,  from  the 
acescent  nature  of  her  food,  or  from  other  causes  which  are  not 
appreciable,  may  disagree  with  the  infant,  and  be  imperfectly 
digested. 

The  most  common  cause  of  indigestion  in  the  infant  is  artifi(^ial 
feeding.  This,  in  the  cities,  is  productive  of  a  great  amount  of 
gastric  and  intestinal  derangement  and  disease.  The  younger  the 
infant,  the  less  likely  is  it  to  thrive  if  brought  up  by  hand. 

Whatever  care  may  be  bestowed  in  the  preparation  of  its  food, 
whether  cow's  or  goat's  milk  or  farinaceous  substances  be  used, 
there  is  seldom  that  healthy  nutrition  which  is  observed  in  infants 
who  receive  the  natural  aliment.  The  "swill  milk"  in  common 
use  among  the  poor  families  of  this  city  is  totally  unfit  for  children 
of  any  age,  and  is  apt  to  produce  flatulence,  acidity,  and  indiges- 
tion. Acute  indigestion  occurs  in  children  of  any  age  from  food 
unsuitable  in  quality  or  quantity,  which  produces  gastralgia  and 
other  symptoms  to  be  detailed  hereafter.  Those  who  suffer 
habitually  from  mal-assimilation  are  especially  liable  to  such  acute 
attacks. 

In  the  period  of  childhood,  chronic  indigestion  is  much  less 
frequent  than  in  infancy,  but  children  are,  perhaps,  more  subject 
than  infants  to  the  acute  form.  This  is  induced  by  ingesta  taken 
in  too  large  quantity,  or  of  a  kind  which  is  with  difiiculty  digested. 
Cherries,  currants,  raisins,  the  parenchyma  of  oranges  and  lemons, 
dried  fruits  and  confectionery,  Avhich  are  so  often  heedlessly  given 
to  children,  are  common  causes  of  acute  attacks  of  indigestion. 
These  substances,  being  but  partially  digested  or  not  at  all,  and 
sometimes  accumulating  for  days  in  the  stomach  or  intestines,  may 
lead  to  a  very  serious  and  dangerous  condition. 

Symptoms. — The  nursing  infant,  if  the  milk  continually  disagree 
with  it,  is  fretful.  It  has  a  discontented  aspect.  It  seldom  §miles, 
and  is  not  amused  by  playthings,  or  is  only  amused  for  a  short 
time.  Its  features  are  pallid,  and  bear  the  appearance  of  faulty 
nutrition.  Its  body  and  limbs  are  more  or  less  wasted,  or  are  soft 
and  flabby.  Vomiting  is  frequently  present,  and  sometimes  a  large 
mass  or  masses  of  caseum  are  ejected,  which  have  evidently  lain  a 
considerable  time  in  the  stomach.  The  bowels  may  be  constipated 
or  loose,  and  the  evacuations  are  unhealthy.  This  state  of  the 
infant  continuing  prevents  the  necessary  rest  of  the  mother,  and 
may  aflect  unfavorably  her  health,  so  as  to  reduce  the  quantity  of 
her  milk,  or  render  it  still  more  unwholesome. 

In  addition  to  the  habitual  indigestion,  these  infants  sometimes 


570  INDIGESTION. 

have  acute  attacks,  similar  to  the  acute  dyspepsia  of  adults,  and 
which  have  been  described  by  writers  as  gastralgia  or  enteralgia. 
Their  countenance  indicates  suffering;  they  utter  sharp  cries,  and 
their  thighs  are  drawn  over  the  abdomen,  indicating  the  seat  of 
the  suffering.  Flatulence  is  common.  By  vomiting  or  an  evacu- 
ation from  the  bowels,  the  offending  substance  is  removed,  and  the 
pain  subsides. 

Indigestion  in  the  spoon-fed  infant  is  similar  to  that  in  the  in- 
fant who  nurses,  except  that  it  is  ordinarily  accompanied  by 
symptoms  of  greater  gravity  and  persistence,  and  there  is  in  the 
spoon-fed  more  liability  to  the  acute  attacks. 

In  those  who  have  advanced  beyond  the  age  of  infancy,  chronic 
indigestion  is  less  frequent  than  in  infants,  but  as  the  diet  of  such 
children  is  prepared  with  less  care,  and  is  less  restricted,  they 
are  very  liable  to  attacks  of  temporary  indigestion.  These  come 
on  suddenly,  and  sometimes  are  so  severe  as  to  endanger  life. 
The  child,  previously  well,  is  suddenly  seized  with  languor;  the 
pulse  becomes  accelerated,  the  face  flushed,  and  surface  hot. 
Drowsiness  compels  him  to  seek  the  bed,  where  he  lies  with  his 
eyes  shut.  He  sometimes  has  headache,  and  a  sensation  of  oppres- 
sion in  the  epigastrium.  The  nervous  system  is  not  unfrequeutly 
affected,  as  shown  by  tenderness  of  a  neuralgic  character  of  the 
body  and  limbs,  sudden  twitching  of  the  limbs  premonitory  of  con- 
vulsions, and  occasionally  severe  and  repeated  convulsions.  These 
alarming  and  really  dangerous  symptoms  speedily  subside  on  the 
removal  of  the  cause.  One  of  the  most  severe  attacks  of  eclamp- 
sia which  I  have  seen  occurred  in  a  boy  eight  or  ten  years  old, 
induced  by  swallowing  the  parenchymatous  portions  of  oranges 
which  he  had  been  in  the  habit  of  eating,  and  which  had  accumu- 
lated in  the  stomach  and  intestines.  The  expulsion  of  the  offend- 
ins:  substance  gave  immediate  relief. 

Sometimes,  but  not  often,  the  symptoms  of  acute  indigestion 
closely  resemble  those  of  pneumonitis.  For  example,  an  infant, 
whom  I  once  treated,  was  seized  at  night  with  fever,  hurried 
respiration,  and  the  expiratory  moan,  which  some  writers  consider 
pathognomonic  of  pneumonitis  or  pleuritis.  These  symptoms  sub- 
sided when  the  bowels  were  freely  opened,  and  currants,  which  had 
been  eaten  the  previous  day,  were  expelled. 

As  the  child  advances  in  years  and  its  general  health  improves, 
the  digestive  function  is  less  frequently  disturbed.  After  the  age 
of  three  or  four  years  the  disease  which  we  are  considering  becomes 


PROGNOSIS  —  TREATMENT,  571 

one  of  much  loss  frequency  and  importance  than  in  infancy  and 
early  chihlhood. 

Indigestion  leads  to  some  of  the  most  common  and  serious  affec- 
tions of  early  life.  In  the  infant,  if  it  continue  a  considerable  time, 
inflammation  of  the  buccal,  oesophageal,  or  gastric  mucous  mem- 
brane, or  of  some  part  of  the  intestinal  tract,  ordinarily  occurs.  In 
the  young  infant  thrush  soon  makes  its  appearance,  and,  whatever 
the  age,  the  cachexia  which  results  from  continued  indigestion  in- 
creases the  liability  to  organic  affections.  Eclampsia  is  the  most 
serious,  and  at  the  same  time  a  frequent,  result  of  temporary  or 
acute  indigestion. 

Prognosis. — In  simple  indigestion  this  is  good.  It  is  doubtful 
01'  unfavorable  when  ulterior  diseases  occur,  and  in  proportion  to 
their  gravity. 

Treatment. — The  first  indication  in  treatment  is  obviously  the 
removal  of  the  cause.  In  acute  indigestion,  when  there  is  reason 
to  believe  that  there  is  some  offending  substance  in  the  stomach 
or  intestines,  if  the  symptoms  occur  soon  after  the  substance  is 
taken,  an  emetic  may  be  administered,  and  ipecacuanha,  in  syrup 
or  powder,  is  safe  and  usually  efficient.  If  several  hours  have 
elapsed,  a  purgative  should  be  given,  as  castor  oil,  or  calomel, 
either  alone  or  in  combination  with  syrup  of  rhubarb. 

If  the  symptoms  are  urgent,  especially  if  convulsions  are  threat- 
ened, we  should  not  wait  for  the  slow  action  of  a  purgative,  but 
should  resort  to  enemata  to  open  the  bowels.  Sometimes  the  pain 
in  acute  indigestion  is  such  as  to  require  the  use  of  opiates.  In 
the  infant  there  is  often  an  excess  of  acid  in  the  stomach  and  in- 
testines, which  is  best  treated  by  alkaline  remedies,  as  lime-water 
in  combination  with  the  opiate.  The  following  mixture  will  be 
found  useful  in  such  cases : — 

R.     Tinct.  Dpii,  or  liq.  opii  compos,  gtt.  xij  ; 
Magnes.  calcinat.  gr.  xij  ; 
Saccli.  alb.  gij  ; 
Aq.  anisi  giss.     Misce. 
Dose,  the  bottle  being  first  shaken,  one  teaspoonful  from  two  to  four  hours  to  a 
child  a  year  old.    If  there  is  much  pain,  it  is  well  to  add  a  little  chloroform  or 
Hoffman's  anodyne  to  the  mixture. 

If  in  the  acute  indigestion  of  infants  there  is  diarrhoea,  the  cam- 
phorated tincture  of  opium  in  combination  with  chalk  mixture 
should  be  given  instead  of  the  above,  fifteen  drops  of  the  one  to  a 
teaspoonful  of  the  other.  Infants  whose  diet  properly  consists 
largely  of  milk,  digest  with  most  difficulty  the  caseum,  which  is 


572  INDIGESTION. 

apt  to  pass  the  bowels  in  an  imperfectly  digested  state,  or  to  collect 
in  a  large  and  firm  mass  in  the  stomach,  causing  gastralgia  and 
renderino;  the  child  fretful  till  it  is  vomited.  I  have  elsewhere  re- 
commended  as  important  to  prevent  these  attacks  of  acute  dys- 
pepsia, the  use  of  the  upper  third  of  the  milk,  which  contains  less 
than  the  average  caseum,  and  the  addition  of  an  alkali  to  the  milk, 
which  retards  the  coagulation  till  it  begins  to  be  acted  upon  by  the 
gastric  juice,  and  tends  to  prevent  the  formation  of  large  and  firm 
caseous  coasrula  in  the  stomach. 

In  chronic  indigestion  the  means  of  relief  are  different.  They 
are  twofold :  first,  as  regards  change  of  diet ;  secondly,  measures 
to  improve  the  digestive  function.  Spoon-fed  infants,  sufliering 
from  habitual  indigestion,  require  the  utmost  care  as  regards  the 
character  of  their  food,  its  preparation,  and  the  times  of  feeding. 
Often  it  is  best,  if  practicable,  to  procure  a  wet-nurse,  and  some- 
times removal  to  a  more  salubrious  locality  is  followed  at  once  by 
improvement  in  the  digestive  function.  If  the  infant  is  already 
wet-nursed,  the  milk  should  be  examined  microscopically  and 
otherwise,  and  inquiry  should  be  instituted  in  reference  to  the 
health  and  diet  of  the  wet-nurse.  Sometimes  a  change  of  wet-nurse 
is  advisable.  For  facts  and  considerations  bearing  on  this  point, 
the  reader  is  referred  to  the  chapters  relating  to  regimen. 

Infants,  as  well  as  children,  with  chronic  indigestion  are  occa- 
sionally much  benefited  by  the  moderate  and  judicious  use  of 
alcoholic  stimulants.  They  should  be  given  sparingly  with  their 
food,  and  should  be  discontinued  as  soon  as  the  digestive  function 
is  fully  restored.  M.  Donn^  and  some  other  French  writers  recom- 
mend the  habitual  use  of  wine  for  infants  even  in  a  state  of  health, 
but  there  are  reasons,  moral  as  well  as  physical,  why  alcoholic 
stimulants  should  only  be  used  as  medicines,  and  never  in  a  state 
of  health. 

If  the  case  is  one  of  simple  or  uncomplicated  indigestion,  tonics, 
either  the  mineral  or  vegetable,  may  be  employed.  In  many  in- 
stances, however,  especially  in  infancy,  gastro-intestinal  inflamma- 
tion has  supervened,  and  in  such  cases  those  tonics  should  be  em- 
ployed which  exert  a  favorable,  or,  at  least,  not  an  unfavorable 
effect  on  the  hypersemic  and  irritable  surface  over  which  they  pass. 

When  indigestion  is  simple,  or  accompanied  by  no  serious  com- 
plication, wine  of  iron,  citrate  of  quinine  and  iron,  and  the  elixir 
of  calisaya  bark,  may  be  mentioned  among  the  safe  and  efficient 
agents  to  improve  the  digestive  function.  The  following  is  also 
a  good  formula  for  cases  of  simple  indigestion: — 


TKEATMENT.  573 

R.  Ferri  citrat.  gr.  xvj  ; 

Bismuth,  citrat.  gr.  xlviij  ; 
A(iuai  5ij.     Misce. 
Dose,  one  teaspoonful  three  or  four  limes  daily  to  a  cliild  of  two  or  three  years. 

The  ferruginous  preparations  are  most  efficacious  in  cases  which 
are  attended  by  signs  of  antcmia. 

Among  the  useful  vegetable  stomachics  and  tonics  may  be  men- 
tioned the  compound  tincture  of  cinchona,  compound  tincture  of 
gentian,  infusion  of  columbo,  fluid  extract  of  columbo,  and  fluid 
extract  of  cinchona. 

If  chronic  indigestion  is  complicated  with  gastro-intestinal 
inflammation,  subacute  or  chronic,  for  this  is  the  form  which  is 
usually  present,  there  are  still  certain  tonics  which  may  be  advan- 
tageously administered.  Columbo  and  the  compound  tincture  of 
cinchona  are  often  useful  in  these  cases,  and  of  the  chalybeates 
wine  of  iron  or  the  tincture  ferri  chloridi,  in  small  doses,  may  be 
safely  administered.  But  the  remedy  which  I  have  found  most 
serviceable,  both  as  a  tonic  and  for  the  inflammatory  disease,  is 
tincture  of  columbo  in  combination  with  the  liquor  ferri  nitratis, 
given  every  four  hours  according  to  the  formula  contained  in  our 
remarks  on  the  treatment  of  intestinal  inflammation. 

I  have  not  alluded  to  the  use  of  pepsin  as  a  remedial  agent  in 
indigestion.  The  theory  of  its  employment  in  atonic  states  of  the 
stomach  is  good,  but  physicians  in  this  country  have,  in  most  in- 
stances, failed  to  observe  that  benefit  from  its  use  which  they  had 
been  led  to  expect,  and  which  seems  to  have  followed  its  employ- 
ment in  the  practice  of  some  of  the  European  physicians.  Perhaps 
the  result  would  have  been  better  had  fresher  and  better  prepara- 
tions of  pepsin  been  prescribed.  Boudault's  pepsin  from  Paris  has 
been  most  used  in  this  country,  but  ordinarily  I  believe  without 
appreciable  benefit.  I  prescribed  it  in  doses  of  two  or  three  grains, 
several  times  daily,  to  foundlings  from  one  to  three  months  old  in 
the  Infant's  Hospital,  but  the  infants  to  whom  it  was  given  did 
not  appear  to  do  better  than  those  from  whom  it  was  withheld. 

The  American  pepsin,  prepared  under  the  intelligent  supervision 
of  Dr.  James  S.  Hawley,  can  be  obtained  in  the  shops  in  the  form 
of  a  powder  and  wine.  From  its  freshness  and  better  taste  it 
possesses  advantages  over  the  French  preparations. 

Infants  aflected  with  diarrhoea  from  indigestion  I  have  often 
observed  to  improve  under  the  use  of  powders  consisting  of  equal 
parts  of  subnitrate  of  bismuth  and  the  American  pepsin,  but  the 
benefit  was  perhaps  more  due  to  the  former  than  the  latter  agent. 


574  CONGESTION    OF    THE    STOMACH  —  GASTRITIS. 

An  infant  of  three  niontlis  can  take  three  grains  of  each  every  three 
hours,  and  one.  of  twelve  months  six  or  eight  grains. 

Dyspepsia  often  rapidly  disappears  by  hygienic  measures  with- 
out the  use  of  medicines,  as  by  removal  from  the  city  to  the 
country,  out-door  exercise,  or,  if  the  patient  is  an  infant,  by  being 
carried  into  the  open  air  daily.  In  infants,  also,  marked  improve- 
ment is  often  observed  on  the  approach  of  the  cool  and  bracing 
weather  of  autumn  and  winter. 

Congestion  of  the  Stomach. 

Passive  congestion  of  the  stomach  is  described  among  the  dis- 
eases of  this  organ  by  Billard ;  but  it  is  a  pathological  state  of 
little  importance  in  itself.  It  occurs  in  new-born  infants,  asphyxi- 
ated at  birth  and  with  difficulty  resuscitated.  In  these  cases  there 
is  generally  intense  capillary  congestion  throughout  the  system. 
The  mucous  membrane  of  the  stomach  is  injected,  but  not  more 
than  that  of  the  mouth  or  intestines.  If  circulation  and  respira- 
tion are  fully  established,  this  injection  of  the  capillaries  subsides. 
1^0  treatment  is  required,  except  measures  to  promote  the  circula- 
tory and  respiratory  functions.  In  cyanosis  and  atelectasis  there 
is  often  general  congestion  of  the  capillaries  of  the  systemic  circu- 
latory system,  on  account  of  the  obstruction  to  the  flow  of  blood 
through  the  heart  in  the  one  disease  and  through  the  lungs  in  the 
other.  There  is  in  these  cases  passive  congestion  of  the  stomach, 
but  not  more  than  of  the  other  organs. 

Gastritis. 

Inflammation  of  the  stomach,  except  when  produced  by  the 
direct  contact  of  some  irritant,  is  rare  in  infancy  and  childhood, 
independently  of  disease  in  some  other  portion  of  the  intestinal 
tract.  Cases  have,  however,  been  reported  in  which  it  was  not 
known  that  any  irritating  ingesta  had  been  taken,  and  in  which  a 
careful  examination  revealed  a  healthy  or  nearly  healthy  state  of 
other  portions  of  the  digestive  tube.  The  subjects  were,  for  the 
most  part,  young  infants.  The  following  is  an  example  related  by 
Eillard:— 

An  infant,  four  days  old,  remarkable  for  the  color  of  his  face 
and  firmness  of  flesh,  refused  the  breast  and  vomited  yellow,  acid 
matter.  On  the  following  day  the  vomiting  had  increased, the  legs 
were  oedematous,  face  pale  and  pinched,  respiration  difficult,  skin 
cold,  pulse  slow  and  irregular,  and  pressure  on  the  epigastric  region 
produced  cries  indicative  of  pain. 


CAUSES.  575 

Tliird  (lay:  general  sinking;  face  thin  and  expressive  of  great 
pain  ;  stools  natural. 

Fourth  and  fifth  days :  condition  the  same.  Death  occurred  on 
the  sixth  day,  and  the  autopsy  was  made  on  the  day  following. 

With  the  exception  of  slight  pneumonitis,  no  disease  was  dis- 
covered in  any  part  of  the  system  hesides  the  stomach.  The 
mucous  membrane  of  this  organ  was  intensely  vascular  near  the 
cardiac  orifice  and  along  the  lesser  curvature.  It  was  also  tume- 
fied, and  could  be  easily  raised  with  the  nail.  In  the  remainder 
of  this  organ  there  was  strongly-marked  capilliform  injection. 

This  case  is  interesting  as  showing  what  may  happen,  though 
rarely.  A  nursing  infant  is  seized  with  gastritis  without  appa- 
rently having  taken  any  irritating  ingesta,  and  without  other  dis- 
ease of  the  digestive  apparatus.  It  is  probable,  however,  that,  in 
cases  like  the  above,  the  cause,  if  ascertained,  would  be  found  in 
the  ingesta:  perhaps  drinks  too  hot,  perhaps  elements  of  colos- 
trum, or  pathological  elements  in  the  milk,  which  might  produce 
gastritis  in  young  infants  in  whom  the  mucous  membrane  is  deli- 
cate and  sensitive. 

Gastritis  is  not  uncommon  in  infancy  in  connection  with  inflam- 
mation of  the  intestines.  The  latter  inflammation  is  sometimes 
apparently  subordinate  to  the  former,  and,  if  such  patients  die,  the 
fatal  result  is  due  mainly  to  the  gastric  disease. 

Causes. — Gastritis  as  I  have  observed  it  in  infants  has  been 
in  most  cases  due  in  great  part  to  the  continued  use  of  improper 
food,  of  food  not  suitable  to  the  age  of  the  child,  and  which  was, 
therefore,  with  difiiculty  digested.  Milk,  acid  or  otherwise  un- 
wholesome, farinaceous  substances,  stale  or  of  an  inferior  quality 
and  not  properly  prepared,  drinks  too  hot  or  too  cold,  may  be 
specified  among  the  causes.  Therefore,  this  disease  is  most  com- 
mon in  bottle-fed  infants,  and  is  comparatively  rare  in  those  who 
receive  abundant  and  wholesome  breast  milk.  Anti-hygienic 
agencies,  apart  from  the  diet,  no  doubt  exert  some  influence  in  the 
production  of  gastritis,  as  they  do  of  stomatitis.  Uncleanliness, 
residence  in  damp  and  dark  apartments,  and  in  an  atmosphere 
loaded  with  noxious  gases,  produce  a  condition  of  system  which 
strongly  predisposes  to  these  inflammations,  if,  indeed,  they  may 
not  be  enumerated  among  the  direct  causes. 

Rilliet  and  Barthez  have  called  attention  to  the  fact  that  certain 
medicinal  substances  given  to  children  occasionally  cause  gastritis. 
They  have  observed  this  eftect  from  the  use  of  tartar  emetic, 
Kermes  mineral,  and  croton  oil.     Gastritis  occurring  in  this  way 


576  GASTRITIS. 

may  or  may  not  be  associated  with  inflammation  in  contiguous 
portions  of  the  digestive  tube.  Elsewhere  I  have  related  a  case 
in  which  gastro-enteritis  occurred  in  a  child  nine  years  old,  after 
having  taken  a  considerable  quantity  of  kerosene  oil  for  spasmodic 

croup. 

Inflammation  of  the  stomach  is  thought  by  some  to  accompany 
measles  and  scarlet  fever  during  the  eruptive  period,  though  the 
proof  of  this  is  not  decisive.  If  it  occur,  it  corresponds  wnth  the  , 
stomatitis  and  cutaneous  inflammation  of  those  diseases,  and  dis- 
appears as  they  subside.  It  is  mild,  and  accompanied  by  few 
symptoms.  I  have,  however,  already  stated,  in  the  remarks  on 
scarlet  fever,  that  I  have  in  a  few^  instances  examined  the  stomachs 
of  those  who  had  died  during  the  eruptive  period  of  these  diseases, 
and  found  them  free  from  any  appreciable  inflammatory  lesion. 

Age. — From  the  records  of  about  seventy  cases  of  inflammatory 
disease  of  the  digestive  mucous  membrane  which  I  have  preserved, 
it  appears  that  gastritis  is  rare  over  the  age  of  six  months.  On 
the  other  hand,  it  is  not  uncommon  in  infants  under  the  age  of 
three  months  who  are  deprived  of  the  breast  milk.  I  have  met 
it  chiefly  in  foundlings  fed  with  the  bottle,  and  having  at  the 
samfe  time  entero-colitis  and  often  also  stomatitis  and  oesophagitis. 
In  these  cases  there  is  sometimes  continuous  or  almost  continuous 
injection  and  thickening  of  the  mucous  membrane,  from  the  lips  to 
near  the  pyloric  orifice  of  the  stomach  and  even  beyond  this  orifice 
in  the  intestines.  The  following  is  an  example  of  gastritis  as  it 
frequentl}'  occurs  in  foundling  institutions : — 

Case. — I\.W.,  female,  two  weeks  old,  was  admitted  into  the  New  York 
Infant  Asylum,  August  24tli,  1865,  anaemic  and  somewhat  emaciated.  It 
was  in  part  Avet-nnrsed,  and  in  part  bottle-fed.  The  emaciation  increased, 
and  nearly  the  entire  buccal  cavitj'  became  covered  witli  the  confervoid 
growth  of  thrush.  On  September  4th,  diarrhwa  commenced.  Borax 
was  used  for  the  mouth,  and  alkalies  and  astringents  to  check  the  diar- 
rha'a,  but  witliout  material  improvement. 

The  following  was  the  record  for  September  Ith  :  "  Cries  almost  con- 
stantly, with  feeble  or  whining  voice ;  still  has  thrush  ;  nurses  and  does 
not  vomit ;  dejections  five  or  six  daily,  and  green ;  pulse  136,  feeble." 
Death  occurred  September  8th. 

Autopsy  September  9th. — Mouth  and  fauces  not  examined;  mucous 
membrane  of  cesophagus  vascular  in  its  whole  extent,  with  slight  thicken- 
ing, but  without  ulceration  ;  mucous  membrane  of  stomach  injected  like 
that  of  the  a'sophagus,  and  somewhat  thickened,  except  in  its  pyloric 
extrerait}^  where  the  appearance  was  natural,  or  nearly  so  ;  the  color  in 
the  central  part  of  the  inflamed  gastric  membrane  Avas  deep  red  ;  no 
thrush  was  noticed,  except  on  the  buccal  surface  during  life ;  along  the 
great  curvature  of  the  stomach  Avere  white  flakes,  resembling  those  of 
thrush,  but  which  were  found  by  the  microscope  to  consist  mainly  of 


SYMPTOMS  —  ANATOMKJAL    CHARACTERS.  577 

oil  glohules  and  epithelial  cells,  without  the  cryptogamic  formation; 
mucous  membrane  of  small  intestines  healthy  in  their  whole  extent,  ex- 
cept slightly  increased  vasculaiity  in  a  few  places  in  the  ileum  ;  mucous 
membrane  of  colon  much  injected  throughout,  except  near  the  ileo-cyecal 
valve,  where  the  vascularity  was  slight ;  in  the  transverse  and  descend- 
ing colon,  the  redness  was  pretty  uniform,  and  the  membrane  was 
thickened,  but  not  ulcerated  ;  solitary  glands  and  Peyer's  patches  some- 
what elevated. 

The  observations  of  Vallcix  show  how  frequently  gastritis  is 
associated  wnth  severe  attacks  of  thrush.  In  twenty-three  of  his 
cases  of  the  latter  disease,  in  which  tlie  condition  of  the  stomach 
was  noted  after  death,  this  organ  presented  inflammatory  lesions 
in  seventeen,  and  in  three  others  appearances  w^hich  may  or  may 
not  have  been  due  to  inflammation. 

Symptoms. — A  difficult}^  exists  in  isolating  and  defining  the 
symptoms  of  gastritis  from  the  fact  that  it  commonly  coexists 
with  other  inflammation  of  the  digestive  tube.  Though  we  may 
never  be  able  to  diagnosticate  this  aflection  as  certainly  as  we  can 
croup  or  pneumonitis,  still,  there  are  symptoms  which  arise  directl}^ 
from  the  gastritis,  and  with  care  we  may  be  able  to  distinguish 
them  from  those  symptoms  which  are  due  to  other  pathological 
states. 

If  gastritis  is  acute,  pain  is  present.  In  the  above  case  from 
Billarcl,  as  well  as  in  a  case  observed  by  myself,  and  related  under 
the  head  of  gelatinous  softening,  there  w^ere  frequent  cries,  and  the 
countenance  indicated  much  suftering,  until  the  stage  of  collapse. 
If  there  is  less  intensity  of  inflammation,  and  the  disease  is  more 
protracted,  as  is  ordinarily  the  case,  the  pain  is  not  so  severe,  and 
it  may  be  so  slight  as  not  to  attract  attention.  Sometimes  there 
is  tenderness,  so  that  pressure  upon  the  epigastric  region  is  badly 
tolerated.  Vomiting  is  regarded  as  one  of  the  most  constant 
symptoms.  The  infant  after  nursing  seems  in  distress  till  the 
milk  is  returned,  but  it  nurses  with  avidity  in  consequence  of  the 
thirst,  if  it  is  not  too  exhausted  or  feeble.  The  dejections  may  be 
quite  regular  throughout  the  disease,  as  in  the  case  from  Billard. 
There  is  ordinarily,  however,  diarrhoea  from  the  presence  of  enterc- 
colitis.  The  pulse  is  sometimes  accelerated,  and  sometimes  nearly 
natural.  The  emaciation  in  gastritis  is  rapid,  since  not  only  the 
milk  is  in  great  measure  vomited,  but  the  digestive  function,  so  far 
as  the  stomach  is  concerned,  is  seriously  impaired.  The  features 
become  wrinkled  and  senile,  the  eyes  hollow,  the  limbs  attenuated, 
and  the  cranial  bones  uneven.     Death  occurs  from  exhaustion. 

Anatomical    Characters. — Simple    gastritis    may   afl:ect    the 
37 


578  GASTEITIS. 

entire  mucous  surface  of  the  stomach,  or  be  limited  to  a  certain 
part.  The  part  which  is  most  likely  to  escape  is  that  towards 
the  pyloric  orifice.  This  portion  of  the  organ  is  sometimes  found 
in  nearly  or  quite  the  normal  state,  while  the  cardiac  half  or  two- 
thirds  are  inflamed.  The  vascularity  of  the  diseased  surface  is  not 
uniform.  In  one  place  there  is  simple  arborescence  ;  in  another 
intense  continuous  redness,  and  between  these  two  extremes  are 
different  grades  of  vascularity.  The  mucous  membrane  is  some- 
what thickened,  softened,  and  the  secretion  of  mucus  increased. 
Extravasation  of  blood  is  not  infrequent  under  the  mucous  mem- 
brane, usually  in  points,  and  the  mucus  may  be  mixed  with  more 
or  less  blood.  Small  shreds  or  portions  of  coagulated  milk  are 
often  found  with  the  mucus  attached  to  the  gastric  surface.  I 
have  observed,  though  rarely,  small  superficial  ulcers  at  the  point 
where  the  inflammation  had  been  most  intense. 

Diagnosis.— In  protracted  cases,  when  entero-colitis  is  present, 
it  is  difficult  to  make  a  positive  diagnosis.  Our  opinion  must 
then  be  little  more  than  a  plausible  conjecture.  In  the  acute 
attacks  we  can  diagnosticate  the  gastritis  with  more  certainty. 
If  a  young  infant  affected  with  thrush  is  seized  with  pain,  and  it 
vomits  often;  if  emaciation  is  rapid,  and  there  is  no  diarrhcea,  or 
diarrhcea  not  sufficient  to  account  for  the  prostration  ;  if  the  buccal 
mucous  membrane,  dotted  with  the  points  of  thrush,  presents  a  dry 
appearance  and  the  deep  red  color  of  severe  stomatitis,  there  can 
be  little  doubt  of  the  presence  of  gastritis.  The  diagnosis  is 
rendered  more  certain  by  signs  of  tenderness,  when  pressure  is 
made  upon  the  epigastric  region. 

Prognosis. — Like  other  inflammations,  gastritis  is  probably 
sometimes  so  mild  that  it  does  not  materially  increase  the  suftering 
or  danger  of  the  child.  This  mild  form  of  the  disease  under 
favorable  circumstances  soon  subsides.  In  other  cases,  by  the  con- 
tinuance or  increase  of  the  cause,  the  inflammatory  process  becomes 
more  severe  and  extensive,  resulting  even  in  disintegration  of  the 
mucous  membrane.  Those  cases  are  especially  severe  and  likely 
to  terminate  fatally,  which  are  protracted  and  accompanied  by 
severe  thrush,  with  a  desiccated  appearance  of  the  mouth,  or  with 
entero-colitis.  Pain,  vomiting,  and  rapid  emaciation  in  such  chil- 
dren indicate  the  speedy  approach  of  death.  Improvement  in  the 
stomatitis  or  entero-colitis  is  a  favorable  indication,  but  these  in- 
flammations may  improve  without  corresponding  improvement  in 
the  gastritis. 

Treatment. — All  food  or  drinks,  except  those  of  a  bland  and 


FOLLICULAR    GASTRITIS.  579 

niiirrltating  nature,  should  be  forbidden.  If  practical^le,  the 
young  infant  shoukl  take  no  nutriment  except  the  mother's  milk 
or  that  of  a  wet-nurse.  As  there  is  an  excess  of  acid  in  inflam- 
mation of  the  mucous  coat  of  the  digestive  tube,  lime-water  may 
be  advantageously  given  in  combination  with  the  breast  milk. 
Opium  is  required  to  relieve  the  pain  and  quiet  the  action  of  the 
stomach.  The  camphorated  tincture  of  opium,  in  doses  of  four  or 
five  drops  to  a  child  a  month  old,  or  the  syrup  of  poppy,  tincture 
of  opium,  or  liquor  opii  compositus,  in  proportionate  doses,  may  be 
administered.  If  there  is  thirst,  a  little  gum-water  should  be 
given  frequently.  If  there  is  much  emaciation  and  the  vital 
powers  are  failing,  it  will  be  necessary  to  resort  to  the  use  of 
stimulants.  Stimulating  enemata  are  preferable  to  stimulants 
given  by  the  mouth.  Much  benefit  may  be  anticipated  from 
local  measures.  Irritation  should  be  produced  upon  the  epigas- 
trium by  mustard  or  other  means,  followed  by  fomentations.  It 
is  rarely,  perhaps  never,  proper  to  use  leeches,  if  the  patient  be  a 
young  infant.  Death  occurs  from  exhaustion,  and  it  is,  therefore, 
important  that  the  vital  powers  should  not  be  reduced.  If  the 
child  is  weaned,  the  diet  at  first  should  be  restricted  to  arrowroot, 
rice-water,  barley-water,  or  similar  bland  substances.  In  advanced 
stages  of  gastritis,  animal  broths  and  jellies  may  be  required. 

Follicular  Gastritis— Diphtheritic  Gastritis. 

The  pathological  character  of  follicular  gastritis  is  similar  to 
that  of  follicular  stomatitis.  It  is  an  inflammation  aflectino-  the 
gastric  follicles  and  ending  in  their  ulceration.  It  is  not  a  fre- 
quent disease ;  it  occurs  in  young  infants.  Billard  observed  fifteen 
cases.  The  symptoms  in  these  patients  were  similar  to  those  in 
simple  gastritis  of  a  severe  form.  The  emaciation  and  prostration 
were  rapid,  and  death  occurred  early.  We  can  only  diagnosticate 
the  gastritis  without  determining  its  follicular  character.  How 
many  recover  it  is  impossible  to  ascertain,  but  the  disease  is  apt  to 
be  fatal  on  account  of  the  intensity  of  the  inflammation,  not  only 
of  the  follicles  but  of  the  intervening  mucous  membrane.  The 
treatment  is  that  of  gastritis. 

DiPHTHEiiiTic  gastritis  is  infrequent.  It  occasionally  occurs 
during  epidemics  of  diphtheria.  Allusion  is  elsewhere  made  to  a 
case  treated  in  the  Nursery  and  Child's  Hospital  of  this  city,  in 
December,  1859.  The  patient,  eighteen  months  old,  previously 
had  had  protracted  entero-colitis,  and  died  exhausted  after  a  brief 
attack  of  diphtheria.     There  were  lesions  referable  to  the  eutero- 


580  SOFTENING, 

colitis,  and  the  body  was  much  emaciated.  The  diphtheritic  exu- 
dation was  found  covering  the  fauces,  epiglottis,  glottis,  to  the 
rima  glottidis,  the  entire  oesophagus,  and  almost  the  entire  stomach. 
The  mucous  surface  underneath  was  injected ;  that  of  the  oeso- 
phagus and  stomach  especially  was  very  vascular,  softened  and 
thickened,  and  the  submucous  connective  tissue  was  infiltrated. 

The  pseudo-membrane,  taken  from  the  epiglottis  and  examined 
under  the  microscope,  presented  an  amorphous  appearance:  no  cells 
were  noticed  in  it,  and  fibrillation  was  not  distinct ;  that  from  the 
stomach  was  found  to  consist  almost  entirely  of  cells,  the  plastic 
corpuscles  of  some  writers,  the  pyoid  of  others.  The  digestive 
process,  so  far  as  the  stomach  was  concerned,  had  evidently  been 
almost  if  not  entirely  susj^ended,  and  hence  in  part  the  sudden 
prostration.  Diphtheritic  gastritis  is  but  a  local  manifestation  of 
a  grave  constitutional  disease. 

Post-Mortem  Digestion,  Softening. 

It  is  now  many  years  since  the  attention  of  the  profession  was 
directed  to  disorganization  of  the  coats  of  the  stomach,  which  is 
sometimes  observed  at  post-mortem  examinations.  John  Hunter 
first  ascertained  that  the  gastric  juice  begins  to  have  a  solvent 
effect  on  the  tissues  of  the  stomach  soon  after  death.  Thouo-h 
Hunter  erred,  when  he  stated  that  the  coats  of  the  stomach  are 
more  or  less  digested  in  all  or  nearly  all  cases,  it  is  certain  that 
post-mortem  digestion  does  take  place  in  many  cadavers,  so  that  a 
few  hours  after  death  the  gastric  mucous  membrane  is  destroyed 
to  a  greater  or  less  extent,  and  occasionally  the  stomach  is  perfo- 
rated or  is  even  severed  from  its  connection  with  the  oesophagus. 
I  have  seen  several  examples  of  this  post-mortem  perforation  in 
infants. 

Some  of  the  cases  of  supposed  pathological  softening  of  the 
stomach  reported  by  the  older  observers,  seem  to  have  been  such 
as  I  have  described,  namely,  cadaveric.  Yet  there  are  two  other 
kinds  of  softening  occurring  in  children,  which  are  strictly  patho- 
logical, the  one  designated  white,  the  other,  by  Cruveilhier,  gela- 
tinous. 

"White  softening  of  the  gastro-intestinal  mucous  membrane 
results  from  deficient  alimentation.  It  has  been  observed  only 
in  anaemic  and  ill-nourished  children.  The  mucous  membrane  in 
such  loses  its  firmness,  and  is  easily  separated  from  the  subjacent 
tissue.  This  disorganization  has  no  connection  with  any  inflam- 
matory process.      It    is   simply  a   disintegration  of  the  mucous 


ITS    NATURE.  581 

membrane  in  conseqnence  of  tlic  low  vitality  of  the  patient, 
whether  or  not  there  are  co-operating  causes.  I  believe  that,  in 
a  large  proportion  of  infants  whose  systems  have  been  reduced 
and  blood  impoverished  for  a  considerable  time,  the  gastro-intes- 
tinal  mucous  membrane  will  be  found  after  death  less  firm  and 
resisting  than  in  those  who  have  been  habitually  robust. 

A  vague  opinion  exists  in  the  minds  of  most  physicians  as  to  the 
nature  and  even  appearance  of  the  so-called  gelatinous  softening  of 
the  stomach,  and  the  following  observations  will  be  cited  in  order 
to  give  a  clearer  idea  of  it. 

Billard  has  recorded  two  cases  with  his  usual  minuteness,  and 
adds:  "What  inference  shall  be  drawn  from  the  preceding  facts 
and  considerations?  JN^one  other  than  that  the  g-elatinous  softening; 
of  the  stomach  consists  in  a  disorganization  of  the  mucous  mem- 
brane of  this  viscus,  caused  by  an  acute  or  chronic  phlegmasia; 
that  this  disorganization  is  characterized  by  an  accumulation  of 
serum  in  the  walls  of  this  organ ;  the  intumescence  and  gelatinous 
consistence  of  the  mucous  membrane  in  a  part  usually  circum- 
scribed, situated  more  frequently  in  the  greater  curvature,  and 
about  which  the  membrane  exhibits  more  or  less  evident  traces  of 
an  acute  or  chronic  phlegmasia.  .  .  .  The  softening  now  under 
consideration  must  not  be  confounded  with  another  kind  of  soften- 
ing" (white) "  which  does  not  usually  succeed  an  acute  phlegmasia." 

Billard  believes  that,  while  gelatinous  softening  results  from 
inflammation  of  the  mucous  membrane,  its  proximate  cause  is  an 
afflux  of  serum  to  the  part  in  which  the  disorganization  occurs. 
In  one  of  the  two  cases  which  be  reports,  he  thinks  that  the  in- 
flammation was  acute,  but  in  the  other  chronic,  and,  therefore, 
presenting  less  vascularity. 

West,  in  speaking  of  gelatinous  softening,  says :  "  Softening  of 
the  stomach  varies  in  degree  from  a  slight  diminution  in  the  con- 
sistence of  the  mucous  membrane,  to  a  state  of  complete  difilu- 
ence  of  all  the  tissues  of  the  organ.  .  .  .  When  the  change  is  not 
far  advanced,  the  exterior  of  the  stomach  presents  a  perfectly 
natural  appearance,  but  on  laying  it  open  a  colorless  or  slightly 
brownish  tenacious  mucus,  like  the  mucilage  of  quince-seeds,  is 
found  closely  adhering  to  its  interior,  over  a  more  or  less  consider- 
able space  at  the  great  end  of  this  organ." 

Cruveilhier  says:  "This  softening  often  proceeds  from  the 
interior  towards  the  exterior.  There  is  at  the  beo-innino;  simnle 
separation  of  the  fibres  by  a  gelatinous  mucus,  and  in  consequence 
the  parietes  are  thickened  and  semi-transparent.  ...  If  the  trans- 


582  SOFTENING. 

formation  be  complete,  the  disorganized  portions  are  removed  layer 
after  layer,  those  which  remain  becoming  gradually  thinner.  The 
peritoneum  alone  resists  for  some  time,  but  at  length  it  is  attacked, 
worn,  and  gives  way,  and  perforation  of  the  stomach  results.  The 
parts  thus  transformed  are  colorless,  transparent,  apparently  inor- 
ganic, completely  deprived  of  vessels,  and  exhaling  an  odor  re- 
sembling that  of  milk." 

Bouchut  remarks :  "  Softening  of  the  mucous  membrane  of  the 
stomach  in  children  at  the  breast  is  not  a  special  disease  which  it 
is  necessary  to  describe  by  itself  This  alteration  is  always  con- 
nected with  other  diseases,  and  is  especially  with  disease  of  the 
large  intestine,  the  knowledge  of  which  fact  has  been  too  long 
neglected.  It  is  the  consequence  of  the  acidity  of  the  liquids 
contained  in  the  digestive  tube  of  young  children,  liquids  which 
are  very  acid  in  the  disease  we  have  above  referred  to." 

Dr.  Carswell  states  that  there  is  a  pathological  softening  of  the 
mucous  membrane  of  the  stomach,  and  that  when  it  occurs  the 
symptoms  may  be  those  of  gastritis  or  enteritis. 

Rokitansky  says  of  this  form  of  softening :  "  If  we  consider,  in 
addition  to  the  above  remarks,  the  uniform  localization  of  the 
disease,  that  in  none  of  its  stages  it  presents,  either  at  the  point  of 
the  softening  or  in  its  vicinity,  hypersemic  injection  or  reddening, 
and  that  we  are  still  less  able  to  demonstrate  upon  the  inner  surface 
of  the  stomach  or  in  the  tissue  of  its  coats  the  products  of  inflam- 
mation, we  are  constrained  to  infer  the  non-inflammatory  nature 
of  the  affection." 

Without  extending  these  extracts,  it  is  seen  that  eminent  au- 
thorities not  only  disagree  in  reference  to  the  cause  of  gelatinous 
softening  of  the  stomach,  but  that  they  also  differ  in  their  descrip- 
tion of  its  appearance.  This  diversity  of  opinion  is  most  likely 
attributable  to  the  fact  that  the  two  kinds  of  softening  have  been 
confounded.  Rokitansky  and  Bouchut  probably  refer  to  cases  of 
white  softening,  which  occurs  in  atonic  state  of  the  tissues  in 
feeble  infants,  and,  therefore,  have  concluded  that  softening  of  the 
stomach  is  not  inflammatory.  I  believe,  from  my  observations,  that 
the  opinion  of  Billard  is  correct,  and  that  true  gelatinous  softening 
is  the  result  of  gastric  inflammation,  sometimes  chronic,  sometimes 
acute.  But  I  have  seen  appearances  which  led  me  to  think  that 
the  immediate  causes  of  the  softening  continue  to  operate  after 
death,  so  that  its  amount  is  less  at  the  time  of  death  than  a  few 
hours  subsequently. 

The  following  case,  which  was  watched  by  myself  with  great 


CASE.  583 

interest  from  beginning  to  end,  is  an  example  of  inflammatory 
softening: — 

Case.— G.  S.,  male,  robust,  was  born  July  10th,  1805,  Tlie  mother  not 
being  able  to  suckle  the  infant,  and  the  danger  of  artificial  feeding  in  the 
warm  months  being  well  understood,  a  wet-nurse  was  procured.  Ahout 
the  14th  of  July,  tliis  wet-nurse  liaving  insufficient  milk,  anotlier  was  pro- 
cured temporarily,  who  suckled  the  infant  till  July  20th,  when  a  tliird 
wet-nurse  was  engaged,  whose  chikl,  healthy  and  tliriving,  was  six  weeks 
old.  Previously  to  this  time  the  infant  appeared  well.  It  had  uniformly 
nursed  vigorously  and  seemed  satisfied. 

On  the  22d  of  July,  thrush,  apparently  mild,  was  observed  in  the 
month,  and  a  powder,  supjjosed  to  be  borax,  and  labelled  such,  was 
obtained  at  a  drug  store,  to  be  used  as  a  wash  for  the  mouth.  This 
powder  was  afterward  ascertained  to  be  alum.  About  five  gi'ains  were 
dissolved  in  as  many  teaspoon fuls  of  water,  and  the  mouth  of  the  child 
was  swabbed  occasionally  with  it.  A  piece  of  bnen,  folded  so  as  to 
resemble  the  tip  of  a  nursing  bottle,  was  occasionally  dip[)ed  into  the 
solution,  and  the  infant  was  allowed  to  suck  it.  The  use  of  the  alum 
was  commenced  about  6  P.M.  In  the  first  part  of  the  evening  the  infant 
slept  considerably,  and  of  course  did  not  nurse  often,  but  about  8  P.M. 
it  began  to  be  very  fretful,  and  it  then  nursed  more  frecjuently.  It 
vomited  once  between  8  and  10  o'clock  P.M.  In  order  to  quiet  the 
infant,  the  tip  soaked  in  the  solution  was  often  applied  to  the  mouth, 
but  there  was  scarcely  any  intermission  in  its  crying.  Through  the 
night  it  vomited  again  once  or  twice,  and  about  the  middle  of  the  night 
had  one  free  liquid  stool,  which  was  passed  with  much  tenesmus.  The 
countenance  of  the  infant  was  indicative  of  suffering,  and  its  thighs  were 
repeatedl}'  flexed  over  the  abdomen,  as  if  that  were  the  seat  of  its  dis- 
tress. Paregoric  in  two-drop  doses  was  several  times  given  through 
the  night,  and  flannel  soaked  with  hot  whiskey  was  applied  to  the 
abdomen. 

Jul}^  23d.  In  ignorance  of  the  cause  of  the  child's  sickness,  another 
wet-nurse  was  obtained  early  in  the  morning,  and  one-sixth  of  a  drop 
of  liq.  opii  compos,  was  given  every  hour,  with  the  effect  of  inducing  a 
little  sleep.  The  tongue  was  very  red,  desiccated,  and  studded  with 
more  numerous  points  of  thrush  than  on  the  previous  day.  It  now 
refused  to  nurse,  apparently  from  soreness  of  the  tongue.  At  each 
attempt  of  the  nurse  to  induce  it  to  take  the  nipple,  it  rubbed  the  mouth 
across  the  breast,  crying  either  from  pain  or  disappointment.  The  alum 
was  not  used  in  the  latter  part  of  the  night  of  the  22d,  but  late  in  the 
morning  of  the  23d  it  was  resumed,  the  mistake  of  the  druggist  not 
being  discovered  till  midday,  when  it  was  estimated  that  about  five 
grains  had  been  used.  Occasionally  a  little  of  the  solution  was  placed 
in  the  mouth  with  a  spoon  so  as  to  be  swallowed,  in  the  belief  that  the 
thrush  aflected  the  oesophagus.  The  infant  continued  to  suffer  much 
during  the  day,  sleeping  at  times  a  few  minutes.  Its  strength  was  evi- 
dently failing;  its  respiration  regular;  pulse  about  140;  its  alvine  dis- 
charges yellow,  of  natural  consistence  and  frequency. 

Evening,  23d.  Surface  hot;  is  very  restless;  pulse  150  to  160;  tongue 
dry,  intensely  red,  and  dotted  with  points  of  thrush.  Is  treated  with 
opiates,  a  little  lime-water,  and  fomentations. 

24th.  In  the  first  part  of  the  day,  nursed  pretty  well;  in  the  latter 
part,  could  be  induced  to  draw  the  breast  only  once  or  twice.     The 


584  SOFTENING. 

symptoms  to-day  were  the  same  as  yesterday,  with  the  exception  of 
greater  emaciation  and  prostration;  cranial  bones  nneven,  and  features 
pinched. 

25th.  Pulse  140  to  14S;  strength  rapidly  failing,  but  it  cries  at  times 
loudlv.  The  milk  of  the  nurse,  placed  in  the  mouth  with  a  spoon,  is 
often  held  a  consideraVtle  time  before  it  is  swallowed,  and  deglutition 
seems  difficult.  Respiration  in  the  first  part  of  the  day  and  previously, 
natural;  in  the  latter  part  of  the  da^*,  accelerated;  dejections  natural; 
no  vomiting;  appearance  of  tongue  more  natural  than  yesterday. 

2Gth.  Died  to-day  in  a  state  of  collapse  at  12^  P.M.  The  hands 
were  cold  several  hours  before  death,  and  the  milk  given  it  was  regur- 
gitated. 

Julopsy  tiventy-tico  hours  after  death. — Much  emaciation;  no  rigor 
mortis;  cranial  bones  uneven;  upper  part  of  the  pharynx  injected  to 
the  extent  of  about  half  an  inch;  but  from  this  point  to  the  stomach 
membrane  healthy;  mucous  membrane  covering  the  cardiac  two-thirds 
of  the  stomach  disintegrated,  alnlost  diffluent,  and  in  places  detached 
from  the  subjacent  tissue;  mucous  coat  of  the  p\-loric  third  of  the  organ 
nearly  healthy;  along  the  edge  of  the  softened  portion  the  mucous 
membrane  was  vascular  to  the  extent  of  a  few  lines  ;  the  muscular  and 
serous  coats  of  the  stomach  underneath  the  softened  portion  were  easily 
torn;  the  mucous  membrane  of  the  small  intestine  presented  in  places 
that  degree  of  vascularity  known  as  arborescence;  there  was  no  destruc- 
tion or  softening  of  its  mucous  membrane;  the  colon  was  healthy 5  the 
stomach  was  nearly  empty;  the  contents  of  the  small  and  large  intestines 
were  natural  in  color  and  consistence;  the  other  viscera  were  healthy; 
in  the  left  pleural  cavity  was  about  an  ounce  of  transparent  serum,  and 
a  less  quantit}^  in  the  right  eavit}'. 

It  cannot  be  doubted  that  the  softening  in  the  above  case  was 
pathological.  The  weather  at  the  time  was  warm,  but  the  infant 
was  placed  on  ice,  and  a  pan  containing  ice  was  kept  upon  the 
abdomen.  This  infant  died  evidently  of  gastritis,  the  accompany- 
ing inflammation  being  subordinate,  and  in  fact  insignificant.  At 
fii-st  it  was  a  question  with  me,  whether  the  alum  might  not  have 
caused  the  gastritis,  so  that  the  case  should  be  properly  placed  in 
the  category  of  deaths  from  swallowing  corrosive  substances.  In 
order  to  determine  this  point,  I  administered  alum  daily  to  two 
kittens,  commencing  when  they  were  seven  days  old.  The  quantity 
given  to  each  was  ten  grains  daily  in  two  doses  for  three  consecu- 
tive days,  and  on  the  two  following  days  five  grains.  The  only 
uniform  result  noticed  was  an  increased  flow  of  saliva,  which 
washed  some  of  the  alum  from  their  mouths,  and  occasionally 
slight  vomiting.  There  was  not  even  any  apparent  inflammation 
of  the  buccal  membrane  from  the  alum. 

Post-mortem  appearances  as  in  the  above  case,  and  similar  ones 
are  recorded  by  Valleix  and  others,  in  which  gelatinous  softening 
coexisted  with  evident  lesions  of  gastritis,  render  it  highly  probable, 


NON-IXFLAMMATORY    DIARRHCEA.  585 

if  iiideefl  they  do  not  demonstrate,  that  the  softening  is  a  result  of 
the  inflammation  at  the  point  where  it  occurs. 

In  Vallcix's  twenty-four  cases  of  what  he  terms  fatal  muguct, 
softenino;  of  the  mucous  membrane  of  the  stomach  was  one  of  the 
most  common  lesions,  and  at  the  same  time,  which  is  the  point  of 
interest,  there  were  signs  which  showed  conclusively  the  presence 
of  gastric  inflammation.  The  common  coexistence  of  the  lesions 
of  gastric  inflammation,  such  as  redness  and  thickening,  with 
gelatinous  softening  of  the  stomach  is  certainly  most  reasonably 
explained  on  the  supposition  that  the  one  results  from  the  other. 

I  am  not  prepared  to  accept  nor  reject  the  theory  of  Billard,  that 
the  immediate  cause  of  the  softening  is  the  afflux  of  serum,  nor 
that  of  Bouchut,  that  it  is  an  excess  of  acid. 

It  has  been  said  that  M.  Baron  was  able  to  diagnosticate  gela- 
tinous softening.  The  symptoms  are  those  of  the  severer  forms  of 
gastritis.  The  vomiting,  great  pain,  restlessness,  sudden  and  pro- 
gressive emaciation,  and,  finally,  collapse  preceding  the  fatal  result, 
are  the  symptoms  on  which  the  diagnosis  is  based.  The  treatment 
should  be  directed  to  the  gastritis. 


CHAPTER  YII. 

DIARRHCEA. 

DiARRHCEA  is  frequent  during  the  whole  j^eriod  of  infancy.  The 
French  writers  describe  several  varieties  according  to  the  character 
of  the  evacuations,  as  acescent,  mucous,  and  serous.  M.  Rostan 
even  describes  fourteen  distinct  kinds.  But  the  tendency  of  medi- 
cal science  in  these  modern  times  is  to  simplify  the  nomenclature 
of  diseases — to  describe  under  a  single  name  those  afl'ections  which 
are  essentially  the  same  though  differing  somewhat  in  their  features. 
jSTow,  all  the  forms  of  diarrhoea  in  the  infant  may  be  so  grouped  as 
to  reduce  the  number  to  not  more  than  three  or  four.  In  this 
way  repetition  and  prolixity  are  avoided,  as  well  as  an  unnecessary 
refinement. 

Non-Inflammatory  Diarrhoea. 

The  most  common  and  the  simplest  form  of  diarrhoea  is  that 
enunciated  in  our  heading.     Though  attended  often   by  an  ana- 


586  NON-INFLAMMATOEY    DIAREHGEA. 

tomical  alteration  in  the  intestines,  the  inflammatoiy  character  is 
absent.  This  disease  is  described  by  some  writers  as  simple,  or 
catarrrhal,  or  spasmodic  diarrhoea.  Many  cases  of  diarrhoea  sup- 
posed to  be  non-inflammatory  are  really  cases  of  entero-colitis,  and 
very  frequently  diarrhoea  not  inflammatory  in  its  commencement 
changes  its  character  and  becomes  such.  This  is  especially  true  of 
such  diarrhoeal  aft'ections  as  are  produced  by  improper  diet. 

Causes. — The  causes  of  non-inflammatory  diarrhoea  are  various. 
Influences,  which  in  the  adult  would  have  no  appreciable  eflect, 
increase  the  number  of  evacuations  in  the  infant. 

A  common  cause  is  food  of  unsuitable  quality  or  quantity.  Food 
that  does  not  digest  well  is  apt  to  stimulate  the  intestinal  follicles 
to  excessive  secretion  and  accelerate  the  peristaltic  action  of  the 
intestines.  In  infants  diarrhoea  is  sometimes  due  to  too  frequent 
feeding.  Many  whose  stomachs  are  overloaded  obtain  relief  by 
vomiting,  but  others  do  not.  The  food  not  needed  for  nutrition 
serves  as  an  irritant,  and  produces  green  and  unhealthy  evacua- 
tions. Dr.  James  Jackson,  in  his  letters  to  a  young  physician, 
calls  attention  to  this  cause  of  diarrhoea. 

The  mother's  milk  or  the  milk  of  the  wet-nurse  may  disagree, 
either  from  some  temporary  derangement  of  her  system,  or  con- 
tinued ill-health,  or  from  causes  which  are  not  understood.  Non- 
inflammatory diarrhoea  in  the  nursling  is  the  immediate  result,  but 
inflammation  may  afterwards  occur.  The  milk  in  these  cases  fre- 
quentl}^  contains  the  elements  of  colostrum. 

Fright  or  strong  mental  impressions  will  also  in  some  children 
increase  the  number  of  evacuations.  This  cause  being  transient, 
the  diarrhoea  soon  subsides. 

Another  cause  is  exposure  to  cold.  Children  who  are  insufii- 
ciently  clothed  in  the  winter  season,  who  are  taken  from  a  heated 
room  into  a  cool  one  without  sufficient  precaution,  or  who  lie  un- 
covered at  night,  are  very  subject  to  diarrhoeal  attacks  from  the 
impression  of  cold  on  the  system. 

The  cause  of  non-inflammatory  diarrhoea  may  exist  in  the  child 
itself.  In  some  children  the  evolution  of  the  teeth  is  attended  by 
a  relaxed  state  of  the  bowels,  which  ceases  when  the  gum  is  pierced. 
Worms  in  the  intestines  may  also  operate  as  a  cause.  Diarrhoea  is 
occasionally  salutary  within  certain  limits,  and  of  course  it  is  not 
strictly  correct  to  call  it  a  disease  when  it  is  a  means  of  relief.  If 
occurring  from  an  excess  of  food  or  from  dentition,  it  may  prevent 
convulsive  seizures. 


SYMPTOMS.  587 

Symptoms. — N'on-inflaminatoiy  diarrhoea  may  come  on  suddenly; 
but  at  other  times  tlicre  arc  precursory  symptoms  continuing  for 
some  days.  "Whether  or  not  there  are  antecedent  symptoms  de- 
pends chiefly  on  the  cause.  If  diarrhoea  occur  from  fright,  or  from 
cokl,  or  from  improper  aliment,  it  commonly  occurs  immediately. 
If  from  painful  dentition,  there  are  previous  symptoms  referable 
to  the  eruption  of  the  teeth. 

The  prodromic  symptoms  are  restlessness  and  disturbed  sleep ; 
sometimes  the  physiognomy  indicates  transient  abdominal  pains. 
Indigestion,  characterized  by  regurgitation,  nausea,  or  even  vomit- 
ing, is  an  occasional  premonitory  condition.  Finally,  diarrhoea  * 
commences.  The  evacuations  differ  much  in  color  and  consistence 
in  diflterent  cases,  and  perhaps  at  different  periods  in  the  same  case. 
In  infants  they  are  apt  to  be  green.  This  color,  which  is  a  source 
of  anxiety  to  the  inexperienced,  and  especially  to  the  parents,  is 
often  produced  by  trivial  causes.  Slight  indigestion  will  produce' 
it.  So  will  excess  of  food,  even  the  most  bland  and  unirritating.. 
Occasionally  the  stools  consist  in  part  of  undigested  portions. of 
food,  especially  the  casein.  In  children  advanced  beyond  the  period 
of  first  dentition  the  evacuations  do  not  differ  materially  in  ap- 
pearance from  those  occurring  in  the  adult.  The  stools  are  usually 
passed  easily,  but  there  is  sometimes  in  infants  more  or  less  tenes- 
mus, if  they  are  acid  or  in  any  way  irritating.  Occasionally  there 
is  a  sensation  of  fulness  in  the  abdomen. 

In  the  form  of  diarrhoea  which  has  been  designated  acescent,  not 
only  is  there  an  acid  odor  and  reaction  of  the  matter  vomited,  but 
also  of  the  stools.  At  night,  since  less  nutriment  is  taken,  and  the> 
patient  is  more  quiet,  the  evacuations  in  non-inflammatory  diar- 
rhoea are  less  frequent  than  in  the  daytime.  If  the  complaint  is 
slight,  there  is  little  desire  for  drink,  but  if  the  stools  are  frequent 
and  thin,  especially  if  they  approach  the  serous  character,  thirst  is 
often  intense;  the  appetite  varies;  the  tongue  is  moist,  and  covered' 
with  a  light  fur ;  there  is  often  more  or  less  meteorism,  but  no 
abdominal  tenderness. 

The  face  in  this  disease  is  pale.  In  a  few  days  if  the  evacua- 
tions continue,  there  is  evident  loss  of  weight  and  flesh.  The 
rotundity  of  the  limbs  is  gradually  lost,  and  the  tissues  become 
soft  and  flabby.  But  in  most  cases,  when  the  affection  has  reached 
this  stage,  its  original  character  is  lost,  and  it  has  become  infla^m- 
matory. 

There  is  no  constant  fever  in  true  non-inflammatory  diarrhoea. 


588  NON-INFLAMMATORY    DIARRHCEA. 

Sometimes  the  pulse  is  accelerated  in  the  latter  part  of  the  day, 
but  usually  only  for  a  short  time. 

Certain  epiphenomena,  as  Bavrier  terms  them,  occur  at  times  in 
non-inflammatory  as  well  as  in  inflammatory  diarrhoea,  for  example 
a  sympathetic  cough,  or,  which  is  more  serious,  cerebral  compli- 
cations. Convulsions  or  stupor,  indicating  the  supervention  of 
spurious  hydrocephalus,  may  occur  in  either  form  of  diarrhoea. 
This  disease  is  described  elsewhere. 

Anatomical  Characters. — The  structural  changes  observed  in 
the  intestines  in  those  who  die  of  non-inflammatory  diarrhoea  have 
been  well  described  by  Billard.  "I  have  seen,"  says  he,  "isolated 
follicles,  and  follicular  plexuses  of  the  intestinal  tube,  in  consider- 
able numbers,  and  developed  without  being  inflamed,  in  twelve 
infants.  There  were  three  aged  from  eight  days  to  three  weeks ; 
two  aged  two  months ;  the  remaining  seven  were  from  nine  months 
to  one  year.  The  follicles  appear  at  the  commencement  of  denti- 
tion. Ten  of  these  children  were  affected  with  diarrhoea  of  liquid, 
white,  mucous  matters.  This  is  really  the  serous  diarrhoea  of  au- 
thors ;  and  every  symptom  leads  to  the  belief  that  there  is  a  direct 
relation  between  the  development  of  these  follicles  and  the  aug- 
mentation of  their  secretion."  .  .  .  "I  do  not  consider  this  morbid 
development  of  the  muciparous  follicles  as  a  true  inflammation. 
Nevertheless,  this  state  of  excitability  which  causes  the  augmenta- 
tion of  their  secretion  is,  as  it  were,  an  intermediate  stage  between 
the  normal  state  and  the  state  of  inflammation."  Barrier's  views 
also  coincide,  in  the  main,  with  those  of  Billard. 

One  of  the  most  common  lesions  observed  in  the  intestines,  in 
those  who  have  died  with  non-inflammatory  diarrhoea,  is,  as  these 
authors  remark,  turgescence  of  the  intestinal  glands.  In  a  large 
proportion  of  cases  these  glands  will  be  found  more  distinct  than 
in  the  healthy  state. 

The  solitary  follicles  of  the  large  intestines,  especially,  are,  in 
most  cases,  elevated,  and  their  central  depression  distinct ;  the 
patches  of  Peyer  are  also  prominent. 

The  following  is  an  example  of  non-inflammatory  diarrhoea  in  a 
young  infant: — 

On  the  7th  of  July,  1865,  a  foundling,  one  month  old,  died  at 
the  Infant  Asylum.  It  was  much  emaciated,  with  eyes  sunken 
and  features  pinched,  at  the  time  of  its  death.  It  was  wet-nursed 
towards  the  close  of  its  life,  but  the  nurse's  milk  was  insufficient. 
It  did  hot  vomit ;  did  not  have  any  marked  acceleration  of  pulse 
(128  per  minute),  and  its  evacuations  were  about  four  daily,  and 


DIAGNOSIS  —  PROGNOSIS.  589 

thin.  The  stomach  and  intestines  were  pale  throughout.  The 
solitary  glands,  particularly  those  in  the  colon,  and  the  patches  of 
Peyer,  were  tumetied  so  as  to  be  visible,  and  somewhat  raised  above 
the  surrounding  surface.  There  was  probably  slight  thickening 
of  the  mucous  membrane,  and  tumefaction  of  the  muciparous 
follicles,  but  these  changes  were  not  clearly  ascertained. 

Diagnosis. — The  only  disease  with  which  there  is  liability  of 
confounding  non-inflammatory  diarrhoea  is  enteritis  or  entero- 
colitis. From  these  it  may  be  diagnosticated  by  the  absence  of 
continued  fever  and  of  abdominal  tenderness.  Sometimes,  indeed, 
it  is  difficult  to  say  whether  the  case  is  non-inflammatory  or 
whether  there  exists  a  moderate  degree  of  inflammation,  though 
practically  the  determination  of  this  point  is  not  important. 

Prognosis. — In  a  large  proportion  of  cases,  non-inflammatory 
diarrhoea  is  not  dangerous.  With  the  adoption  of  suitable  mea- 
sures to  remove  the  cause,  and  the  use  of  medicines  to  control  the 
discharges,  the  patient  recovers.  The  remark  already  made  may 
be  repeated  here,  that  occasionally  diarrhoea  is  salutary  within  cer- 
tain limits,  as  when  there  is  a  foreign  substance  in  the  intestines, 
either  irritating  mechanically  or  by  its  chemical  properties,  and 
which  the  diarrhoea  serves  to  remove. 

The  danger,  in  non-inflammatory  diarrhoea,  arises  from  compli- 
cations, as  spurious  hydrocephalus,  or  from  the  emaciation  and 
exhaustion.  There  may  also  be  danger  of  its  eventuating  in  inflam- 
mation, which  is  always  serious.  "Whether  or  not  the  diarrhoea  is 
in  itself  injurious  to  the  child,  and  a  source  of  danger,  may  be  de- 
termined by  observing  whether  or  not  there  is  emaciation. 

If  the  rotundity  of  the  figure  and  firmness  of  the  tissues  are 
preserved,  showing  that  alimentation  is  still  sufficient,  and  no  com- 
plication arises,  the  diarrhoea  is  not  as  a  rule  injurious.  In  infants 
that  over-nurse  and  do  not  vomit  the  surplus  milk,  the  evacuations 
are  sometimes  green  and  frequent,  and  yet  fulness  of  figure  is  pre- 
served, and  the  development  of  the  body  proceeds  as  usual.  The 
same  state  is  sometimes  observed  in  the  diarrhoea  accompanying 
dentition.  In  these  instances  a  moderately  relaxed  state  of  the 
bowels  is  not  injurious.  On  the  other  hand,  diarrhoea  attended  by 
emaciation  or  softness  or  flabbiness  of  the  flesh  requires  immediate 
treatment.  Many  lives  are  lost  by  the  neglect  of  such  patients 
till  they  are  so  reduced  that  they  can  no  longer  derive  any  material 
benefit  from  remedial  measures.  This  fatal  neglect  is  common 
during  the  process  of  dentition. 


590  NON-INFLAMMATORY    DIARRH(EA. 

Treatment. — It  is  necessary,  in  order  to  treat  successfully  diar- 
rhoea in  infancy  and  childhood,  to  ascertain  the  cause,  and,  so  far 
as  possible,  to  remove  it.  It  is  not  till  the  cause  ceases  to  operate, 
that  we  can  expect  a  satisfactory  result  from  medication.  The 
disease  may  be  temporarily  relieved  by  medicine,  but  it  usually 
returns  at  once  when  treatment  is  omitted,  unless  the  patient  is 
removed  from  the  influence  of  the  agencies  which  produce  it. 
These  remarks  are  especially  applicable  to  the  diarrhoea  of  infants. 
With  them  very  generally,  when  affected  with  this  complaint, 
there  is  some  fault  as  regards  the  quantity  or  quality  of  food.  At- 
tention to  this  matter  will  show  the  need  of  a  chano-e  of  wet-nurse, 
or,  if  the  infant  be  spoon-fed,  a  change  in  the  character  of  its  food 
or  the  mode  of  preparation  or  even  in  the  quantity  given.  In 
many  cases,  by  change  in  the  diet,  and  the  adoption  of  hygienic 
measures,  the  complaint  ceases,  so  as  to  require  no  medication.  If 
medicines  are  needed,  and  the  symptoms  are  not  urgent,  it  is  occa- 
sionally advantageous  to  commence  treatment  by  the  use  of  some 
of  the  milder  purgatives  in  small  doses.  In  the  infant^  in  whom 
the  dejections  are  so  generally  acid,  an  alkaline  laxative,  or  a  laxa- 
tive conjoined  with  an  alkali,  often  has  a  good  effect  as  pi'eliminary 
treatment.  Half  a  teaspoonful  to  one  teaspoonful  of  castor  oil,  or 
a  proportionate  dose  of  Rochelle  salts,  removes  any  acid  or  irri- 
tating substance  from  the  intestines,  and  is  followed  by  a  diminution 
in  the  number  of  stools.  The  improvement,  however,  without 
subsequent  treatment,  is  usually  only  for  a  day  or  two.  The  use 
of  a  purgative  should,  therefore,  be  considered  as  preliminary  to 
other  measures.  In  this  city  a  purgative  dose  of  castor  oil  is  often 
given  as  a  domestic  remedy  in  infantile  diarrhoea,  the  beneficial 
effect  from  it  having  popularized  its  use  for  this  purpose.  Trous- 
seau usually  gave  Rochelle  salts. 

If  there  has  been  previous  constipation,  and  the  diarrhoea  has 
just  commenced,  a  purgative  is  obviously  indicated.  With  the 
operation  of  this  medicine  there  is  frequently  marked  improve- 
ment. West  says:  "Provided  there  be  neither  much  pain  nor 
much  tenesmus,  and  the  evacuations,  though  watery,  are  foecal,  and 
contain  little  mucus  and  no  blood,  very  small  doses  of  the  sulphate 
of  ma(j;nesia  and  tincture  of  rhubarb  have  seemed  to  me  more 
useful  than  any  other  remedy: — 

R.  Magnesise  sulphatis  5j  ; 

Tinct.  rhei  5j  ; 

Syr.  zingiberis  3j ; 

Aqute  carui  3ix.     Misce. 
3j  ter  die  for  children  one  year  old ; 


TREATMENT.  591 

and  I  seldom  fail  to  observe  from  it  a  speedy  diminution  in  tlic 
frequency  of  tlie  action  of  the  bowels,  and  a  return  of  the  natural 
cliaracter  of  the  evacuations." 

In  diarrhoea  of  infants,  due  to  indigestion,  and  attended  by 
acidity,  the  following  prescription  is  sometimes  useful.  By  im- 
proving digestion  and  correcting  acidity,  it  has  a  beneficial  effect 
on  the  diarrhoea.  The  cases  are,  however,  in  my  experience  ex- 
ceptional in  which  this  is  the  proper  remedy. 

R.  Pulv.  ipccacuanliJB  gr.  j  ; 
Pulv.  rbei  gr.  ij  ; 
Sodfe  bicarb,  gr.  iv-vij.     Misce. 
Divide  in  cbart.  No.  xij.     One  powder  every  four  to  six  bours  to  an  infant  one 
year  old. 

The  effect  of  laxative  medicines  employed  for  the  purpose  of 
correcting  the  functions  of  the  gastro-intestinal  surface  is  uncer- 
tain. If  there  is  no  improvement  from  their  use  within  two  or 
three  days,  the}^  should  be  omitted.  We  must  rely  on  astringents, 
opiates,  and,  in  infants,  also  on  alkalies.  If  the  symptoms  are 
urgent,  if  the  evacuations  are  frequent  and  exhaustive,  ,these 
agents  should  be  employed  from  the  lirst.  Much  harm  is  often 
done,  and  precious  time  lost,  by  prescribing  laxative  mixtures 
when  opiates  and  astringents  are  required.  I  have  known  them 
to  aggravate  the  complaint,  when,  by  change  of  measures,  there 
was  immediate  improvement.  The  majority  of  cases  of  non-in- 
flammatory diarrhoea,  at  the  period  when  the  physician  is  called, 
are  best  treated  by  the  use  of  astringents  and  ojiiates  exclusivelv, 
proper  directions  at  the  same  time  being  given  in  reference  to  the 
diet  and  hygienic  management. 

In  the  diarrhoea  of  infants  the  compound  powder  of  chalk  and 
opium  is  an  excellent  medicine,  containing,  as  it  does,  an  astrin- 
gent with  the  opiate  and  alkali.  It  may  be  given,  in  doses  of 
three  grains,  to  a  child  one  year  old,  every  three  hours.  I  ordina- 
rily employ  it  with  double  its  quantity  of  subnitrate  of  bismuth, 
and  know  no  better  remedy  for  ordinary  cases.  The  following  is 
also  an  old  but  useful  prescrij^tiou  in  the  simple  diarrhoea  of 
infants : — 

R.  Tinct.  opii  campborat., 
Tinct.  catecbu,  aa  gij  ; 
Mistur.  cretaj  |j.     Misce. 
Dose,  one  teaspoonful  every  two  to  four  bours  to  a  cbild  one  year  old. 

If  there  is  no  acidity  of  the  evacuation,  the  following  mixture 
will  often  be  found  effectual,  which  is  similar  to  one  recommended 
by  Dr.  West :— 


592  INTESTINAL    INFLAMMATION    OF    INFANCY. 

R.  Acid,  tannic,  gr.  xij  ; 
Tinct.  opii  gtt.  xij  ; 
Tinct.  cinnamom.  comp.  gij ; 
Saccli.  alb.  gss ; 
Aq.  cinnamom.  5^-     Misoe. 
Dose,  one  teaspoonful  every  two  or  three  hours,  or  longer  time,  according  to  the 
evacuations. 

Kino,  krameria,  or  logwood  may  be  used  in  place  of  the  astrin- 
2'ents  mentioned  above.  If  the  diarrhoea  is  due  to  the  feeble 
digestive  powers  of  the  patient,  and  its  food  is  therefore  irritating, 
powders  of  pepsin  and  subnitrate  of  bismuth  may  be  employed. 

In  the  treatment  of  non-inflammatory  diarrhoea  occurring  in 
infancy,  it  is  rarely  necessary  to  use  the  mineral  astringents,  as 
acetate  of  lead  or  nitrate  of  silver.  If  the  patient  is  not  relieved 
by  opiates,  alkalies,  and  the  vegetable  astringents,  and  by  })roper 
regimen,  in  all  probability  there  is  inflammation  of  the  intestinal 
mucous  membrane.  In  patients  over  the  age  of  two  or  three 
years,  simple  diarrhoea  approaches  in  character  that  of  the  adult, 
and  the  treatment  appropriate  for  the  adult  is  proper  in  these 
cases,  allowance  being  made  for  the  difference  of  age.  In  infants, 
in  whom  this  disease,  if  protracted,  is  very  liable  to  eventuate  in 
spurious  hydrocephalus,  stimulants  are  often  required  at  an  early 
period,  on  account  of  the  prostration  and  feeble  power  of  endur- 
ance. 


CHAPTEE   VIII. 

INTESTINAL  INFLAMMATION  OF  INFANCY. 

It  is  customary  with  writers  to  treat  of  inflammation  of  the 
small  and  large  intestines  in  infancy  as  a  single  disease,  for  the 
following  reasons :  First,  the  symptoms  of  colitis,  at  this  period  of 
life,  do  not  ordinarily  differ,  in  any  marked  degree,  from  those  of 
enteritis.  The  tormina,  tenesmus,  and  abdominal  tenderness,  which 
characterize  colitis  in  childhood  and  adult  life,  are  ordinarily 
lacking,  or  are  not  appreciable  by  the  observer;  and  the  muco- 
sanguineous  evacuations  are  oftener  absent  than  present.  On 
account  of  this  absence  of  symptoms,  Bouchut  says:  "Dysentery 
is  a  very  rare  disease  amongst  young  children.  Its  existence 
might  even  be  denied,  if  it  had  not  been  observed  at  the  period 
of  some  severe  epidemics  of  dysentery."    If  Bouchut  refers,  by  the 


INTESTINAL    INFLAMMATION    OF    INFANCY.  593 

term  dysentery,  to  tlie  ordinary  }»hcnomena  of  that  disease,  his 
remark  is  correct ;  but,  as  regards  the  lesions,  it  is  erroneous,  for 
colitis  is  not  so  rare  in  infancy  as  his  remark  implies.  Billard, 
after  analyzing  eighty  cases  of  intestinal  inflammation  in  infants, 
says:  "From  this  calculation,  it  is  evidently  very  difficult  to  make 
a  correct  diagnosis  of  inflammation  of  the  intestinal  tube  in  suck- 
ing infants,  yet  it  would  seem  as  if  the  proper  signs  of  enteritis  or 
ileitis  were  the  rapid  tympanitis  of  the  abdomen,  the  diarrhoea, 
accompanied  with  vomiting;  while  in  colitis,  diarrhoea  alone, 
without  tympanitis,  is  the  most  freqtient."  And  again:  "In  con- 
sequence of  the  impossibility  we  have  found  to  exist  of  tracing 
with  exactitude  the  series  of  symptoms  proper  to  inflammation  of 
the  different  portions  of  the  digestive  tube,  we  shall  content  our- 
selves with  presenting  an  analytical  sketch  of  the  causes,  symp- 
toms, and  ordinary  course  of  inflammation  of  the  mucous  membrane 
of  the  intestines  in  general."  ♦ 

The  frequent  absence  of  any  pathognomonic  symptom  or  sign,  by 
which  to  determine  the  exact  seat  of  intestinal  inflammation  in 
the  infant,  is  admitted  bv  recent  observers  as  well  as  Billard. 

The  second  reason  why  intestinal  inflammation  in  the  infant  is 
described  as  a  single  disease  is,  that  enteritis  and  colitis  are  in 
the  majority  of  cases  coexistent.  This  will  be  seen  when  we  come 
to  speak  of  the  anatomical  characters. 

I  have  hesitated  in  selecting  a  term  for  this  inflammation.  The 
expression  inflammatory  diarrhoea,  used  by  West,  is  objection- 
able, because  it  designates  a  disease  by  a  symptom  when  there  are 
well-marked  lesions.  To  the  expression  entero-colitis,  employed 
by  Bouchut,  Meigs,  and  others,  there  is  this  objection,  that  some- 
times the  disease  is  only  enteritis,  and  sometimes  colitis ;  whereas 
entero-colitis  would  imply  the  presence  of  both  inflammation  of  the 
small  and  the  large  intestines.  Barrier  uses  the  expression  gastro- 
intestinal inflammation,  but  in  a  large  proportion  of  cases  gastric- 
inflammation  is  absent.  I  have  treated  of  gastritis  as  an  indepen- 
dent afltection,  and  it  seems  proper  to  exclude  it  from  our  descrij)- 
tion  of  the  intestinal  disease,  except  as  a  complication. 

Although  I  prefer  the  term  intestinal  inflammation,  I  shall  use, 
in  describing  the  disease,  the  expressions  inflammatory  diarrhoea 
and  entero-colitis  as  synon3mious,  in  order  to  avoid  too  frequent 
repetition  of  words. 

Intestinal  inflammation  is  one  of  the  most  common  and  fatal 
of  infantile  diseases.      It  is  the  great  summer  epidemic  of  the 
cities,  in  this  country.     Unfortunately  for  a  correct  understanding 
38 


594  INTESTINAL    INFLAMMATION    OF    INFANCY.  i 

of  its  prevalence  and  mortality  in  this  city  and  perhaps  elsewhere, 
it  is  very  generally  in  the  summer  months  when  obstinate,  and 
especially  when  fatal,  called  cholera  infantum,  although,  in  its 
symptoms  and  nature,  it  is  very  different  from  that  disease. 

Intestinal  inflammation  is  often  a  protracted  complaint,  having 
ordinal ily  a  mild  commencement,  while  the  true  cholera  infantum 
begins  abruptly,  is  characterized  by  violent  symptoms,  and  rapid 
and  extreme  exhaustion.  The  two  diseases  are,  however,  often 
associated  as  cause  and  effect. 

The  1500  fatal  cases  of  so-called  cholera  infantum,  reported  every 
summer  in  this  city,  are,  with  now  and  then  an  exception,  cases  of 
inflammation,  generally  protracted.  In  like  manner,  the  excess  of 
reported  cases  of  infantile  marasmus,  in  the  second  half  of  the 
year,  over  those  reported  in  the  tirst  half,  should  be  added  to  the 
statistics  of  intestinal  inflammation.  This  excess,  which  is  noticed 
every  year  in  the  mortuary  tables  of  this  city,  is  due  mainly  to  the 
death  of  those  wasted  infants  who  have  lino-ered  with  entero-colitis 
from  the  summer  months.  Their  marasmus  is  simply  a  result  of 
the  protracted  inflammation. 

Causes. — Inflammatory  disease  of  the  intestines  in  infancy,  I 
have  said,  is  chiefly  a  summer  affection — at  least,  in  the  cities. 
Occasionally  it  is  observed  in  the  winter,  and  it  is  then,  when  not 
due  to  error  of  diet,  produced  by  exposure  to  cold.  Infants  who 
are  taken  from  warm  to  cold  rooms,  or  into  the  open  air,  by  heed- 
less nurses,  or  who  sleep  uncovered  at  night,  are  especially  liable 
to  this  disease.  Entero-colitis  produced  by  this  cause  occurs  both 
in  the  country  and  city. 

In  these  cases  the  inflammatory  process  may  not  commence  sud- 
denly. There  is  often  a  premonitory  stage  of  simple  diarrhoea, 
the  first  efi'ect  of  the  impression  of  cold.  Indeed,  in  a  very  large 
proportion  of  cases,  whatever  the  cause,  non-inflammatory  precedes 
inflammatory  diarrhoea. 

The  influence  of  the  summer  season  in  the  production  of  this 
disease  is  forcibly  shown  by  the  death  statistics  of  this  city.  Thus, 
for  the  five  years  ending  with  1863,  there  were  6379  deaths  reported 
from  cholera  infantum,  and  of  these  all  but  166  occurred  in  the 
months  from  June  to  October  inclusive.  The  deaths  reported  for 
the  same  years  from  diarrhoea,  dysentery,  and  inflammation  of  the 
bowels,  were  5914,  of  which  3919  occurred  in  the  months  from 
June  to  October.  '  Of  the  5914,  the  number  under  the  age  of  five 
years  was  3257. 

Those  familiar  with   the  diseases  of  this   city,  and   especially 


CAUSES.  595 

with  the  autopsies  of  infants,  will  agree  that  four-fifths  of  the 
above  cases  which  were  reported  as  cholera  infantum  or  diarrhoBa 
were  cases  of  intestinal  inflammation.  There  is  no  one  disease, 
except  consumption,  so  prevalent  and  fatal  in  this  city  as  infantile 
entcro-colitis  during  the  period  of  its  epidemic  occurrence  in  the 
summer  months. 

The  epidemic  commences  about  the  middle  of  May.  From  this 
time  there  is  a  gradual  increase  in  the  number  affected,  till  the 
months  of  July  and  August,  when  the  disease  attains  its  maximum 
prevalence  and  mortality.  During  the  months  of  September  and 
October,  the  number  of  seizures  and  of  deaths  gradually  abates 
till  the  epidemic  character  is  lost.  It  is  thus  seen  that  the  preva- 
lence of  intestinal  inflammation  of  infancy  in  the  city  bears  a 
close  relation  to  the  degree  of  summer  heat.  That  the  high  tem- 
perature of  summer  is  not  in  itself  sufficient  to  produce  entero- 
colitis is,  however,  obvious.  In  elevated  localities  in  the  country 
there  may  be  intense  and  long-continued  heat,  and  yet  in  such 
places  intestinal  inflammation  of  infants  is  not  common.  It  is  no 
doubt  the  noxious  exhalations  from  various  sources  with  which 
the  atmosphere  is  loaded,  as  a  consequence  of  the  heat,  which 
render  the  disease  so  prevalent  in  certain  localities  in  the  summer 
months.  The  exact  character  of  these  exhalations  or  vapors  is  not 
fully  known,  but  the  following  facts  are  clearly  established  by 
many  observations. 

Entero-colitis  prevails  most  on  low  grounds  near  the  sea-shore. 
Thus,  it  is  common  in  many  parts  of  Long  Island,  on  Staten  Island, 
and  on  the  flats  of  Westchester  County.  Experienced  and  observ- 
ing physicians  of  this  city  do  not  send  infants  affected  in  the 
summer  months  with  entero-colitis  to  these  localities,  but  to  the 
high  grounds  west  of  the  Hudson,  and  to  the  hilly  parts  of  JS'ew 
Jersey,  where  there  is  comparative  immunity  from  the  disease,  and 
recovery  is  more  certain  and  speedy. 

But  the  state  of  atmosphere  which  is  most  favorable  for  the 
development  of  entero-colitis  is  found  only  in  the  cities.  The 
filthy  streets  containing  more  or  less  decaying  animal  and  vege- 
table matter,  the  crowded  and  unclean  tenement  houses,  the  ne- 
glected privies,  the  slaughter  houses,  pig-pens,  bone-boiling  estab- 
lishments, and  the  like,  are  so  many  sources  of  the  most  deleterious 
effluvia,  which,  inspired  by  the  infant,  produce  diarrhoea  and  in- 
testinal inflammation.  Those  squares  of  the  city  where  sanitary 
regulations  are  most  neglected  are  the  very  ones  where  the  mor- 
tality from  this  cause  is  largest. 


596  INTESTINAL    INFLAMMATION    OF    INFANCY. 

In  the  year  1864  the  Citizens'  Association  of  the  City  of  IsTew 
York  effected  a  complete  and  thorough  sanitary  inspection  of  New 
York  island,  and  it  was  interesting  as  well  as  painful  to  note  the 
facts  observed  by  the  inspectors  in  reference  to  the  prevalence  of 
the  so-called  cholera  infantum  (chiefly  entero-colitis)  along  the 
streets  and  in  the  alleys  where  the  causes  of  insalubrity  were  most 
abundant. 

Thus,  one  inspector  says,  of  this  disease,  it  "  has  probably  con 
signed  many  more  to  the  grave  during  the  past  summer  than  all 
other  diseases  in  my  inspection  district.  In  every  case  examined,  I 
have  found  it  associated  with  some  well-marked  source  of  insalu- 
brity. Vegetable  and  animal  decomposition  has  been  the  most 
prominent  cause,"     Another  inspector  says  of  the  same  disease: 

"  It  was  found  between  the and avenues,  where  the  street, 

at  every  visit,  was  found  in  an  indescribably  filthy  state,  in  conse- 
quence of  deposits  of  garbage  and  slops.  This  was  particularly 
noticed  in  front  of  the  premises  where  cholera  infantum  had  oc- 
curred." Such  was  the  uniform  testimony  of  all  the  inspectors. 
In  the  tenement  houses  and  in  portions  of  the  city  occupied  by 
the  poor,  where  the  sources  of  insalubrity  are  most  numerous,  I 
believe,  from  personal  observation,  that  a  majority  of  the  infants 
are  more  or  less  aflected  with  diarrhoea,  often  of  an  inflammatory 
character,  during  the  months  of  July,  August,  and  September. 
In  the  more  salubrious  localities  of  the  city,  there  is  less  of  this 
disease,  but  even  here  the  liability  to  it  is  great,  on  account  of  the 
proximity  of  so  many  sources  of  impure  air. 

But  there  is  another  and  an  important  element  in  the  causation 
of  intestinal  inflammation  in  the  infant.  I  refer  to  the  diet. 
Many  an  infant  that  now  falls  a  victim  would  escape  the  disease, 
but  for  some  fault  in  the  character  of  its  food.  Those  infants  in 
the  city  who  are  bottle-fed  from  birth  rarely  go  through  the 
summer  without  being  affected  with  diarrhoea,  and  a  majority 
of  such,  if  under  the  age  of  six  months,  when  the  warm  weather 
commences,  are  saved  from  dangerous  if  not  fatal  inflammation 
only  by  removal  to  the  pure  air  of  the  country. 

In  the  families  of  the  poor  the  food  which  is  given  as  a  substi- 
tute for  the  mother's  milk  is  very  apt  to  disagree  with  the  feeble 
digestive  powers  of  the  infant.  The  swill  milk,  about  which  so 
much  has  been  said  and  written,  is  in  common  use  in  this  city 
among  these  people,  or  has  been  till  recently.  This  milk,  in  the 
proportion  of  its  ingredients,  and  sometimes  even  in  its  chemical 
character,  is  very  different  from  the  milk  of  healthy  and  well-fed 


CAUSES.  597 

cows  of  the  country.  Infants  to  whom  this  milk  and  other  im- 
proper articles  of  diet  are  given  are  the  first  to  suffer  with  diar- 
rhoea as  warm  weather  commences,  and  finally  with  entero-colitis. 

It  is  seen  that  the  causes  of  intestinal  inflammation  of  infancy 
as  it  prevails  in  the  cities  during  the  summer  are  mainly  twofold, 
atmospheric  and  dietetic — an  insalubrious  state  of  the  air  which 
the  infant  breathes,  and  unsuitable  food.  Among  the  poor  of  the 
cities,  both  these  causes  conspire  to  produce  the  diarrhoeal  maladies. 
It  is  easy,  then,  to  see  why  there  is  so  much  intestinal  disease  and 
so  great  mortality  among  the  infants  of  the  city  poor.  Moreover, 
on  account  of  their  feeble  powers  of  resistance  and  endurance  they 
are  especially  liable  to  be  affected  by  morbific  agencies. 

It  is  a  common  belief  in  the  profession  that  dentition  is  one  of 
the  chief  causes  of  diarrhoea  in  the  infant,  whether  inflammatory 
or  non-inflammatory. 

There  is,  indeed,  great  liability  to  this  disease  during  the  period 
of  dental  evolution.  The  following  statistics,  which  were  mostly 
collected  during  my  term  of  service  in  one  of  the  city  dispensaries, 
and  which  comprise  all  the  cases  of  diarrhoea  under  the  age  of 
about  five  years  which  were  brought  into  that  institution  for  treat- 
ment during  the  summer  months  of  my  attendance,  show  the  pre- 
ponderance of  cases  in  the  time  of  teething.  Most  of  these  cases 
were  apparently  inflammatory. 

Stage  of  Dentition.  No.  of  Cases. 

No  teeth 47 

Cutting  incisors 106 

' '      anterior  molars 41 

"      canines 40 

"      last  molars 20 

Having  all  the  teeth 28 


Total 28: 


0, 


It  is  seen  that  although  a  large  majority  of  the  above  cases 
occurred  during  dental  evolution,  yet  in  a  certain  proportion, 
about  one  in  four,  teething  could  not  operate  as  a  cause.  My  own 
opinion  is  that  dentition  is  an  occasional  cause  of  simple  diarrhoea 
though  a  subordinate  one,  but  evidence  is  wanting  that  it  is  suffi- 
cient of  itself  to  produce  inflammation.  The  diarrhoea  of  dentition 
is  probably  non-inflammatory,  terminating  in  inflammation,  if  such 
a  result  follow  by  the  co-operation  of  other  and  distinct  causes. 
This  subject  is  treated  of  in  our  remarks  relative  to  dentition. 

An  important  predisposing  cause  of  intestinal  inflammation  in 
infants  is  the  rapid  development  of  the  intestinal  crypts  and 
follicles.     This  development,  which  increases  the  liability  to  or- 


598  INTESTINAL    INFLAMMATION    OF    INFANCY. 

ganic  diseases  of  the  intestines,  is  coincident  with  dentition.  An- 
other important  cause  remains  to  be  noticed,  namely,  weaning. 
"Weaning  is  a  subject  to  which  less  attention  is  given  than  its 
importance  demands.  The  summer  succeeding  the  change  of  diet 
is  always  in  the  city  a  time  of  great  danger  to  the  infant  from 
diarrhoeal  aifections.  Mothers  uniformly  speak  with  dread  of  the 
second  summer.  In  this  city,  nearly  every  infant  taken  from  the 
breast  between  the  months  of  April  and  October  very  soon  be- 
comes aiFected  with  diarrhoea,  which,  if  not  inflammatory  in  its 
commencement,  soon  becomes  such.  Weaning  in  the  cool  months 
involves  less  danger,  but  even  then  the  succeeding  summer  is  one 
of  peril.  I  have  memoranda  of  the  time  of  weaning  in  forty-six 
infants  who  were  affected  with  diarrhoea  apparently  from  its  dura- 
tion and  obstinacy  of  an  inflammatory  character. 

"Weaned  in  spring  or  summer 35 

"        "  autumn  or  winter  .        .  JL 11 

W  46 

The  reader  is  referred,  for  other  particulars  in  reference  to  wean- 
ing, to  the  chapter  devoted  to  this  subject. 

The  above  facts  and  statistics,  to  which  more  might  be  added, 
suffice  to  show  the  causative  relation  of  foul  atmosphere  and  inju- 
dicious feeding  to  the  intestinal  inflammation  of  infancy. 

Intestinal  inflammation  also  occurs  as  a  complication  of  certain 
diseases,  especially  the  eruptive  fevers.  It  is  the  opinion  of  some, 
that  in  measles  and  scarlatina  there  is  mild  inflammation  of  the 
intestinal  mucous  membrane,  coexisting  with  the  eruption  upon 
the  skin,  and  disappearing  with  it.  But  in  a  proportion  of  cases, 
most  frequently  in  measles,  a  more  intense  inflammation  arises, 
constituting  a  serious  complication.  The  peculiar  intestinal  in- 
flammation in  typhoid  fever  is  well  known. 

Age. — My  observations  in  reference  to  the  age  at  which  this 
disease  occurs  were  made  in  the  summer  months,  and,  therefore, 
relate  to  the  summer  epidemic.  The  cases  embraced  in  the  follow- 
ing table  were  nearly  all  observed  between  the  months  of  May  and 
October  inclusive: — 

Age.  No.  of  Cases. 

5  months  or  under 58 

From  5  months  to  12 313 

"    13      "        "  18 174 

"    18      "        "24 93 

"   24      "        "36 36 

Total 576 


SYMTTOMS.  599 

This  table  shows  tluat  the  infant  under  the  age  of  six  months  is 
less  liable  to  entero-colitis  than  between  the  ages  of  six  months 
and  two  years.  The  small  comparative  number,  however,  affected 
under  the  age  of  six  months,  I  attribute  to  the  fact  that  most  of 
the  infants  under  this  age  were  wet-nursed.  Observations  made 
in  the  institutions  of.  this  city  in  which  foundlings  are  i'oceived 
show  that  the  younger  the  infant  is,  the  more  liable  it  is  to  be 
affected  with  this  disease,  under  unfavorable  conditions  of  atmos- 
phere and  diet.  Thus,  in  the  infant's  service  of  Charity  Hospital, 
prior  to  the  adoption  of  wet-nursing,  a  large  proportion  of  the 
foundlinofs  received  died  of  well-marked  entero-colitis  in  the  first 
and  second  months,  and  very  few  lived  till  the  age  of  six  months. 
A  similar  fact  was  observed  in  the  N'ew  York  Infant  Asylum  in 
Bloomingdale.'  During  my  term  of  service  in  this  institution,  I 
preserved  notes  of  forty-nine  fatal  cases,  which  I  diagnosticated 
entero-colitis,  and  in  many  of  which  post-mortem  examinations 
were  made.  Of  these  cases,  •feighteen  wore  one  month  old  or  under, 
fifteen  from  one  month  to  three,  eight  from  three  to  six,  and  only 
eight  over  the  age  of  six  months. 

Symptoms. — Intestinal  inflammation  in  the  infant  usually  com- 
mences with  moderate  diarrhoea.  At  first  there  may  be  no  appre- 
ciable anatomical  alteration  of  the  mucous  membrane  except  simple 
turgescence  of  the  follicles.  The  number  of  evacuations  at  this 
period  frequently  does  not  exceed  four  to  six  daily.  The  color  and 
consistence  of  the  dejections  vary.  The  color  is  sometimes  yellow 
at  this  early  stage  of  the  disease,  and  sometimes  green,  especially 
in  young  infants.  "Whatever  the  color  or  appearance  of  the  stools, 
there  is  great  uniformity  in  one  respect,  and  that  is  their  acidity. 
Litmus  paper  is  reddened  by  them,  and  they  have  a  decidedly  acid 
odor.  Often  there  is  from  the  commencement  more  or  less  fretful- 
ness  and  febrile  reaction. 

In  a  few  days,  the  disease  continuing,  the  infant,  whose  stomach 
was  at  first  retentive,  begins  to  vomit.  This  symptom  I  found, 
from  observations  made  in  1863  and  1864,  in  the  summer  entero- 
colitis of  infants,  commences  in  less  than  a  week  in  the  majority 
of  cases,  though  the  time  varies  greatly.  In  consequence  of  the 
vomiting  and  diarrhoea,  the  patient  becomes  pallid,  the  flesh  soft 
and  flabby,  and  soon  there  is  evident  emaciation.     If  there  is  fret- 

•  This  institution  was  discontinued  within  a  year  from  its  establishment,  all  con- 
nected Avith  it  becoming  discouraged  from  the  great  mortality  of  the  foundlings, 
who  were  chiefly  bottle-fed. 


600  INTESTINAL    INFLAMMATION    OF    INFANCY. 

fulness  in  the  beginning  of  the  sickness,  it  now  ceases,  and  the 
patient  lies  quiet,  having  an  exhausted  appearance.  As  the  disease 
advances,  the  features  become  pinched  and  wrinkled.  The  hollow- 
ness  of  the  cheeks  and  sunken  state  of  the  eyes  are  in  striking 
contrast  with  the  appearance  j)resented  before  the  inflammation 
commenced.  So  feeble  is  the  muscular  tonicity  in  advanced  cases, 
that  the  orbicularis  oris  and  orbicularis  palj^ebrarum  lose  in  great 
part  their  contractile  power,  and  the  mouth  and  eyes  continue  open 
during  sleej). 

In  the  beginning  of  the  disease  the  tongue  is  moist  and  covered 
with  a  light  fur.  At  a  more  advanced  stage  it  is  dry,  and  in 
dangerous  forms  of  the  disease  the  buccal  membrane  is  red,  the 
gums  swollen,  and  sometimes  ulcerated,  and  in  young  children 
thrush  is  apt  to  appear. 

Vomiting,  commencing,  as  I  have  said,  at  a  later  period  than 
the  diarrhoea,  continues,  unless  relieAd  by  medication  or  a  favor- 
able change  of  the  disease.  It  is  soMfetimes  very  intractable.  It 
is  in  most  cases  associated  with  an  excess  of  acid  in  the  stomach, 
and  is  probably  mainly  due  to  this,  except  at  an  advanced  stage  of 
the  inflammation.  The  substance  vomited  has  a  sour  odor,  and 
produces  a  decided  reaction  with  litmus  paper.  It  contains  coagu- 
lated casein  and  undigested  particles  of  whatever  food  has  been 
given.  When  the  vital  powers  are  much  reduced  and  the  inflam- 
mation is  violent  or  protracted,  spurious  hydrocej^halus  is  present 
or  threatening,  and  the  vomiting  appears  then  to  be  due  to  the 
cerebral  aflfection. 

The  stools  sometimes  continue,  during  the  whole  course  of  the 
entero-colitis,  of  nearly  the  same  character  as  at  first.  In  other 
cases  they  vary,  at  different  periods,  in  color  as  well  as  consistence. 
They  sometimes  have  a  putty-like  appearance,  from  the  partly 
digested  casein;  at  other  times  they  are  brown  and  offensive.  A 
very  common  appearance  is  that  which  has  been  likened  to  spinach 
or  chopped  vegetables;  occasionally  the  stools  consist  largely  of 
mucus,  with  perhaps  a  little  blood — the  mucous  diarrhoea  of 
Barrier.  This  occurs  when  colitis  is  a  principal  part  of  the 
disease.  The  evacuations  are  seldom  so  watery  as  in  true  cholera 
infantum. 

Occasionally  they  are  yellow  when  passed,  but  become  green  on 
exposure  to  the  air,  or  from  chemical  reaction  resulting  from 
admixture  of  the  urine. 

The  microscojnc  character  of  the  stools  in  entero-colitis  is  inter- 
esting.    Aside  from  undigested  casein,  I  have  found  unaltered 


SYMPTOMS.  601 

fibres  of  meat,  crystalline  formations,  epithelial  cells,  single  or 
arranged  regularly  in  clusters,  as  if  detached  from  the  villi, 
mucus,  sometimes  blood,  and,  in  one  case,  an  appearance  resem- 
bling three  or  four  crypts  of  Lieberkuhn  united.  If  the  stools  are 
green,  colored  masses  of  various  sizes,  but  mostly  small,  are  also 
seen  with  the  microscope.  The  microscopic  elements,  then,  are 
the  excrementitious  substances,  particles  of  undigested  food,  in- 
flammatory products,  and  epithelial  cells  or  fragments  of  the 
mucous  membrane,  thrown  off  by  the  inflammatory  process. 

The  'pnlse  in  cntero-colitis  is  accelerated.  There  is  frequently 
increased  heat  of  surface  in  the  commencement,  but,  as  the  disease 
continues,  the  vital  powers  soon  become  reduced,  and  the  surface 
is  either  of  the  natural  temperature  or  cool.  As  death  approaches, 
the  pulse  gradually  becomes  more  frequent  and  feeble,  and  the 
extremities,  sometimes  for  hours  before  life  is  extinct,  have  a 
cadaverous  pallor  and  colduj^s.  The  skin,  in  intestinal  inflam- 
mation, is  generally  dry,  a'^  the  urinary  secretion  diminished. 
In  severer  forms  of  the  disease,  attended  by  frequent  evacuations 
from  the  bowels,  the  infant  does  not  pass  its  urine  oftener  than 
once  or  twice  daily.  The  imperfect  action  of  the  skin  and  kidneys 
is  a  noteworthy  feature  of  the  inflammation.  The  advanced 
stages  of  entero-colitis  are  apt  to  be  complicated  by  two  cutaneous 
affections,  namely,  erythema  between  the  thighs,  probably  pro- 
duced by  the  acid  and  irritating  character  of  the  stools,  and  boils 
upon  the  forehead  and  scalp.  The  latter  sometimes  extend  down 
to  the  pericranium,  and  leave  permanent  depressed  cicatrices, 
^'^he*  external  irritation  caused  by  the  furuncular  affection  has 
often  seemed  to  me  conservative,  as  it  occurs  at  the  time  when 
there  is  danger  of  passive  congestion  of  the  brain  and  serous  effu- 
sion. When  entero-colitis  is  protracted,  and  the  patient  is  much 
reduced,  remaining  constantly  in  the  recumbent  position,  except 
when  held  in  the  arms  of  the  mother  or  nurse,  another  symptom 
frequently  arises,  namely,  a  dry  cough,  which  continues  till  the  close 
of  life,  if  the  case  be  fatal,  and  subsides  slowly  if  the  disease  termi- 
nate favorably.  The  complication  which  gives  rise  to  this  symptom 
will  be  considered  hereafter.  As  death  approaches,  the  infant 
sometimes  becomes  more  fretful;  it  turns  j)eevishly  from  play- 
things, rolls  its  head, or  the  head  has  an  unsteady  movement;  and 
sometimes  the  stomach  is  more  irritable.  The  experienced  physi- 
cian rightly  interprets  these  symptoms  as  the  forerunner  of  cerebral 
accidents.  In  other  cases  there  is  too  great  prostration  even  for 
the  exhibition  of  restlessness,  and  the  infant  lies  quiet.     As  death 


G02  INTESTINAL    INFLAMMATION    OF    INFANCY. 

approaches,  the  infant  becomes  drowsy.  The  limbs  are  cool.  It 
refuses  to  nurse,  or,  if  spoon-fed,  takes  nutriment  apparently  with- 
out relish.  The  pupils  are  contracted,  and  insensible  to  light. 
The  eyes  are  bleared,  and  a  puriform  secretion  occasionally  collects 
between  the  lids.  The  stools  are  less  frequent,  and  the  vomiting, 
if  previously  present,  ceases.     Death  occurs  quietly. 

Sometimes,  however,  convulsive  movements  precede  death,  gene- 
rally slight,  as  of  one  arm,  or  of  the  limbs  or  one  side.  Uraemia 
may  be  the  immediate  cause  of  death  in  certain  cases. 

In  chronic  entero-colitis  there  is  extreme  emaciation  for  a  con- 
siderable time  before  death.  The  skin  of  the  extremities  lies  in 
wrinkles;  the  joints,  from  contrast,  a^^pear  enlarged,  and  the  fingers 
and  toes  elongated ;  the  angular  projections  of  the  bones  are  pro- 
minent. The  hollowness  of  the  cheeks  and  eyes  causes  the  infant 
to  appear  much  older  than  it  really  is.  Death  occurs  in  a  state  of 
extreme  exhaustion. 

The  above  description  applies  to  infantile  entero-colitis,  as  it  so 
frequently  occurs  in  the  cities.  It  is  sometimes  much  more  violent, 
attended  by  much  greater  febrile  reaction,  and  is  more  speedily 
fatal.  Especially  is  this  the  case  when  it  is  due  to  the  impression 
of  cold:  such  cases  are  not  infrequent  in  the  winter  months,  in  the 
country  as  well  as  city. 

Instead  of  the  mild  and  gradual  commencement  which  I  have 
described,  infantile  entero-colitis  may  be  preceded  by  violent 
symptoms — a  true  cholera  morbus.  Vomiting  and  purging,  more 
or  less  severe,  precede  the  inflammation.  Among  my  records  are 
cases  which  commenced  in  the  summer  season  from  eating  goose- 
berries, currants,  cherries,  and  cheese :  the  cholera  morbus  pro- 
duced by  these  indigestible  substances  ending  in  protracted  inflam- 
mation. 

Cholera  infantum,  in  which  the  symptoms  from  the  first  are 
violent  and  alarming — a  disease  attended  by  vomiting  and  frequent 
watery  stools,  occasionally  ends  in  the  establishment  of  intestinal 
inflammation;  and,  as  there  are  no  symptoms  by  which  it  is  possible 
to  determine  precisely  when  the  inflammation  begins,  it  seems  as 
if  the  inflammation  itself  had  this  violent  commencement.  But 
the  severe  choleraic  symptoms  usually  abate  before  the  inflamma- 
tion is  established. 

Anatomical  Characters. — Billard  says:  "In  eighty  cases  of 
inflammation  of  the  intestines  that  I  examined  with  great  care, 
there  were  thirty  of  entero-colitis,  thirty-six  of  enteritis,  and 
fourteen  of  colitis."     M.  Legendre,  in  twenty-eight  cases  of  diar- 


ANATOMICAL    CHARACTERS.  G03 

rhoBa,  found  colitis  alone  in  nine,  and  in  the  cases  in  which  ente- 
ritis occurred  colitis  was  also  present.     Rilliet  and  Barthcz  state, 
that  in  certain  rare  instances  almost  the  entire  digestive  tube  is 
affected ;  that  in  exceptional  cases  the  principal  lesion  is  found  in 
the  small  intestines,  while,  on  the  other  hand,  the  large  intestine 
is  the  part  of  the  alimentary  canal  which  is  most  frequently  and 
intensely  inflamed.      Billard   describes  four   kinds  of  intestinal 
phlegmasia :    First,  erythematic ;  second,  with  altered  secretion ; 
third,  follicular;  fourth,  with  disorganization  of  tissue.     In  some 
of  the  best  works  on  diseases  of  children,  published  subsequently 
to  that  of  Billard,  different  forms  of  inflammation  are  described, 
according  to  the  presence  or  absence  of  certain  anatomical  changes, 
as  ulceration  or  softening.     Practically  little  is  gained  by  such  a 
division  of  the  general  disease,  and  the  lesions  which  are  made 
the  basis  of  the  division  are  often  merely  the  result  of  severe  and 
protracted,  simple  or  erythematic,  inflammation.     I  have  records 
of  the  post-mortem  appearances  in  eighty-two  cases  of  intestinal 
inflammation  in  the  infant.     Eleven  of  these  occurred  in  private 
or  dispensary  practice ;   about   fifty  in  the  Nursery  and  Child's 
Hospital,  and  the  remainder  in  the  Infant  Asylum.     Since  pre- 
serving these  records,  I  have  witnessed  a  larger  number  of  post- 
mortem examinations  of  infants  who  died  of  this  disease  in  these 
institutions,  and  the  lesions  corresponded  in  general  with  those 
already  observed.     The  question  may  properly  be  asked,  can  in- 
flammatory hypergemia  of  the   intestinal   mucous   membrane  be 
distinguished  from  simple  congestion  if  there  is  no  ulceration  and 
no  appreciable  thickening  of  the  intestine?     This  is  sometimes 
difiicult,  and  it  is  possible  that  occasionally  I  have  recorded  as  in- 
flammatory what  was  simply  a  congestive  lesion,  but  I  do  not 
think  that  I  have  incorporated  a  suflficient  number  of  such  cases 
to  vitiate  the  statistics.     In  a  large  proportion  of  the  autopsies 
there  was  manifest  thickening  of  the  intestinal  mucous  membrane 
or  other  unequivocal  evidence  of  inflammation.     The  following  is 
an  analysis  of  the  eighty-two  cases : — 

The  upper  part  of  the  small  intestine,  embracing  the  duodenum 
and  jejunum,  was  found  inflamed  in  twelve  cases.  It  was  free 
from  inflammation,  and  of  a  pale  color,  in  fifty-one  cases.  The 
ileum  was  inflamed  in  forty-nine  cases,  and  the  coecal  portion,  in- 
cluding the  ileo-coecal  valve,  was  the  part  in  which  the  inflamma- 
tion was  uniformly  most  intense  and  to  which  it  was  often  confined. 
In  sixteen  cases  there  was  no  ileitis,  and  in  thirteen  no  enteritis 
whatever.     Therefore,  the  ileum  was  inflamed  in  all  but  three  of 


60J:  INTESTINAL    INFLAMMATION    OF    INFANCY. 

the  cases  of  enteritis,  in  which  the  records  give  the  exact  location 
of  the  disease.  In  fourteen  cases  there  was  vascularity  in  streaks 
or  in  patches,  or  simple  arborescence  in  some  part  of  the  small 
intestines,  the  records  not  stating  its  exact  location. 

In  most  cases  the  inflamed  mucous  membrane  was  perceptibly 
thickened.  Occasionally,  especially  if  the  vascularity  was  slight, 
the  thickening  was  scarcely  appreciable.  In  one  case  there  was 
80  much  tliickening  of  the  ileum  next  to  the  ileo-coecal  valve  that 
the  mucous  coat  appeared  as  if  closely  studded  with  small  warts. 
Ulcers  of  small  size  were  found  in  the  mucous  membrane  of  the 
small  intestines  in  five  cases.  These  ulcers  in  one  case  were  in  the 
jejunum,  in  two  in  the  ileum,  and  in  two  in  both  these  divisions 
of  the  intestine.  They  were  for  the  most  part  quite  superficial, 
and  circular  or  oval. 

It  is  seen  from  the  above  records  that  the  portion  of  the  small 
intestine  most  frequently  inflamed  was  the  ileum.  The  inflamma- 
tion usually  aifected  the  ileo-coecal  valve,  and  extended  from  it  to 
a  greater  or  less  extent  along  the  small  intestine.  In  general, 
when  inflammatory  patches  were  found  in  difierent  parts  of  the 
small  intestine,  those  in  the  ileum  nearest  the  ileo-ccecal  valve 
presented  the  greatest  vascularity  and  thickening.  Billard  noticed 
in  his  cases  the  frequency  and  intensity  of  the  inflammation  in 
the  terminal  portion  of  the  ileum,  and  the  consequent  thickening 
of  the  ileo-coecal  valve,  and  conjectured  that  the  vomiting  so  com- 
mon and  obstinate  in  enteritis  might  be  due  to  obstruction  at  the 
ileo-ccecal  orifice  in  consequence  of  this  thickening.  I  have  often 
seen  the  orifice  reduced  to  a  very  small  size  from  the  hyperemia 
and  thickening  of  the  valve,  but  have  not  seen  any  accumulation 
above  it  or  other  evidence  of  obstruction. 

The  inflamed  mucous  membrane  was  softened  in  greater  or  less 
degree  according  to  the  intensity  of  the  inflammation.  Sometimes 
the  vessels  of  the  submucous  connective  tissue  were  injected,  and 
this  tissue  infiltrated.  The  softening  of  the  mucous  coat,  and  the 
firmness  of  its  attachment  to  the  parts  underneath,  varied  consider- 
ably in  different  specimens.  I  was  able,  in  cases  in  which  there 
was  considerable  softening,  to  detach  readily  the  mucous  coat  with 
the  nail  or  back  of  the  scalpel,  within  so  short  a  period  after  death 
that  it  was  evident  that  the  change  of  consistence  could  not  have 
been  cadaveric. 

The  infants  in  whom  the  duodenum  and  jejunum  presented  the 
inflammatory  lesions  were,  with  few  exceptions,  under  the  age  of 


ANATOMICAL    CHARACTERS.  605 

tliree  months,  and  in  many  of  these  cases  there  was  hypersemia  of 
the  ii'astric  mucous  membrane,  and  in  some  also  stomatitis. 

In  all  the  cases  except  one,  namely,  in  eighty-one,  there  were 
lesions  indicating  inflammation  of  the  mucous  membrane  of  the 
colon.  In  thirty-nine,  the  inflammation  had  afl:ected  nearly  or 
(|uite  the  entire  extent  of  this  portion  of  the  intestine  ;  in  fourteen, 
it  was  confined  to  the  descending  portion  entirely,  or  almost 
entirely ;  in  twenty-eight  cases,  the  records  state  that  colitis  was 
present,  but  its  exact  location  was  not  mentioned.  In  eighteen  of 
the  examinations,  the  mucous  membrane  of  the  colon  was  found 
ulcerated.  According  to  these  statistics,  there  is  colitis  in  nearly 
every  case  of  intestinal  inflammation  in  infancy,  and  in  a  large 
proportion  of  cases  also  ileitis.  The  portion  of  the  colon  which 
is  most  frequently  inflamed  is  that  in  and  immediately  above  the 
sigmoid  flexure.  If  the  colitis  affects  other  portions  also,  it  is 
nevertheless  in  this  part  that  we  find  the  most  marked  inflamma- 
tory lesions. 

The  solitary  glands,  both  of  the  large  and  small  intestines  and 
Peyer's  patches,  are  involved  in  nearly  all  cases  of  this  disease. 
Even  in  non-inflammatory  diarrhoea  they  become  tumefied,  so  as 
to  be  distinctly  visible  and  somewhat  elevated.  In  entero-colitis, 
as  we  have  already  seen,  they  present  different  appearances,  ac- 
cording to  the  degree  and  duration  of  the  inflammation.  In 
recent  cases,  and  in  parts  of  the  intestine  where  the  inflammatory 
action  has  been  mild,  there  is  often  no  perceptible  change  of  these 
glands  except  slight  enlargement  with  vascularity.  This  enlarge- 
ment is  most  apparent  if  the  intestine  is  viewed  by  transmitted 
light,  when  not  only  the  glands  are  seen  to  be  swollen,  but  their 
central  dark  points  are  also  quite  distinct.  If  there  is  a  higher 
grade  of  inflammation,  or  inflammation  more  protracted,  the  volume 
of  the  solitary  follicles  is  so  increased  that  they  rise  above  the 
common  level  and  present  a  papillary  appearance.  Peyer's  patches 
are  in  a  corresponding  degree  thickened. 

The  enlargement  of  these  glands  is  due  to  hyperplasia,  namely, 
an  augmentation  in  the  number  of  the  elementary  cells.  The 
ulceration  in  the  cases  which  I  have  examined  appeared  to  be 
primarily  and  chiefly  follicular.  .  "While  some  of  the  solitary 
glands  in  a  specimen  were  found  simply  tumefied,  others  were 
slightly  ulcerated,  and  others  still  nearly  or  quite  destroyed.  The 
ulcers  were  usually  from  one  to  three  lines  in  diameter,  circular 
or  oval,  with  edges  a  little  raised,  and  red.  They  resembled  in 
aiDpearance  the  ulcers  in  follicular   stomatitis.      In  one  or  two 


606  IXTESTIXAL    INFLAMMATION    OF    INFANCY. 

iustances  I  have  seen  small  coagula  of  blood  in  the  ulcers,  and  I 
have  also  seen  ulcers  which  had  evidently  been  larger,  having 
partially  healed.  The  principal  seat  of  the  ulcers  was  in  the 
descending  colon.  They  were  either  found  in  this  portion  of  the 
intestine  only,  or,  if  occurring  elsewhere,  they  were  here  most 
abundant. 

Those  in  whom  I  have  found  ulcers  have  been  ordinarily  over 
the  age  of  six  months,  which  is  the  time  when  there  is  greatest 
development  and  activity  of  the  glandular  apparatus.  In  none  of 
the  cases  observed  by  me  were  Peyer's  patches  ulcerated,  though 
generally  tumefied. 

In  cases  in  which  the  caput  coli  was  inflamed,  I  have  sometimes 
found  the  mucous  membrane  of  the  appendix  vermiformis  also 
injected  and  thickened.  In  one  case  only  was  there  pseudo- 
membrane  upon  the  inflamed  surface.  This  was  in  the  descending 
colon,  and  it  was  thin  like  a  film.  The  rectum  presented  no  in- 
flammatory or  other  lesions,  or  but  slight  lesions  in  comparison 
with  those  in  the  colon.  Often,  when  there  was  almost  general 
colitis,  the  rectum  was  found  of  a  pale  color,  or  but  slightly 
vascular.  This  may  explain  the  rare  occurrence  of  tenesmus  in 
infantile  entero-colitis.  The  amount  of  mucus  secreted  from  the 
intestinal  surface  in  this  disease  is  considerably  in  excess  of  the 
normal  quantity.  It  often  forms  a  layer  upon  the  mucous  mem- 
brane of  the  intestines,  and  appears  in  the  stools,  mixed  with 
epithelial  cells  and  sometimes  with  blood  or  pus.  If  the  quantity 
of  mucus  appearing  in  the  stools  is  considerable,  the  disease  has 
sometimes  been  designated  mucous  diarrhoea,  or  mucous  disease ; 
but  there  does  not  seem  to  me  suflS.cient  reason,  either  anatomical 
or  clinical,  for  considering  it  a  distinct  affection. 

The  mesenteric  glands  are  ordinarily  enlarged,  unless  in  very 
young  infants.  They  are  frequently  found  as  large  as  a  large  pea, 
or  even  larger,  and  of  a  light  color,  from  the  anaemic  state  of  the 
infant.  In  exceptional  instances  certavn  of  them  are  found  to  have 
undergone  cheesy  degeneration.  The  enlargement  of  these  glands, 
like  that  of  the  solitary  follicles  and  Peyer's  patches,  is  from 
hyperplasia.  The  condition  of  the  stomach  was  recorded  in  sixty- 
nine  cases.  In  forty-two  it  was  healthy ;  in  seventeen  red,  ap- 
parently inflamed;  in  seven  of  a  pink  color;  and  in  three  there 
were  ulcerations,  probably  cadaveric.  The  usual  healthy  condition 
of  the  stomach  is  a  noteworthy  fact,  taken  in  connection  with  the 
frequent  vomiting,  in  entero-colitis.  I  have  stated  elsewhere  that 
stomatitis  is  also  a  common  complication  in  protracted  and  grave 


ANATOMICAL    CHARACTERS. 


607 


cases,  accompanied  by  sponginess  of  the  gums,  which  bleed  if 
pressecl  or  rubbed.  The  buccal  surface  in  these  cases  is  more  vas- 
cular than  natural,  and,  if  the  vital  powers  are  much  reduced, 
superficial  ulceration  is  not  infrequent,  especially  of  the  gums.  In 
infants  under  the  age  of  three  or  four  months,  a3sophagitis  is  also 
a  common  accompaniment  of  entero-colitis. 

Thrush,  though  a  frequent  complication  under  the  age  of  three 
or  four  months,  is  rare  in  older  infants.  Thrush,  in  infants  over 
the  age  of  eight  or  ten  months,  occurring  in  connection  with  in- 
testinal inflammation,  is  an  unfavorable  prognostic  sign,  indicating 
a  gravity  of  the  intestinal  disease,  which  commonly  eventuates  in 
death. 

There  exists  an  opinion  in  the  profession  that  the  liver  is  in 
fault  in  this  disease,  especially  in  that  form  of  it  which  I  have 
described  as  a  summer  epidemic  of  the  cities.  This  opinion  is, 
probably,  less  prevalent  than  formerly,  but  it  is  still  held  by  many, 
and  it  influences,  more  or  less,  the  choice  of  therapeutic  agents. 
In  the  appendix  (E)  is  a  table,  which  presents  the  condition  of 
the  liver  in  thirty -two  cases  of  this  disease.  These  cases  occurred 
during  the  summer  epidemic. 

There  was  no  evidence,  from  the  post-mortem  appearance  of  the 
liver  in  these  cases,  of  any  congestion,  or  torpidity,  or  hyper- 
activity, or  perverted  secretion.  The  size  of  the  liver  was  in 
some  cases  very  diflerent  in  those  of  about  the  same  age,  but 
probably  there  was  no  greater  difierence  than  usually  obtains 
among  glandular  organs  within  the  limits  of  health.  The  fol- 
lowing table  gives  the  weight  of  the  liver  in  twenty  cases  in 
which  the  weight  of  this  organ  and  the  age  of  the  patient  are 
recorded : — 


Age. 

Agp. 

4  weeks 

5  ounces. 

10  months  . 

6:f  ounces 

2  months 

.      H    " 

13       " 

6 

2       " 

3i     " 

14      "        . 

9        " 

4       "            .         . 

5       " 

15       " 

6 

5       "            .         . 

G^     " 

15       " 

7i       " 

5       " 

9       " 

15       " 

U      " 

7       " 

Ah     " 

16      " 

6 

7       "            .         . 

6       " 

19       " 

A^       " 

7       "            .         . 

H    " 

20       "        .         . 

9i       " 

9      " 

8       " 

23       " 

15 

I  do  not  have  access  to  tables  giving  the  weight  of  the  healthy 
liver  at  diflerent  ages,  but  in  none  of  the  above  cases  did  the  size 
or  the  weight  seem  to  me  to  be  above  the  healthy  standard,  except 


603  INTESTINAL    INFLAMMATION    OF    INFANCY. 

in  one,  in  which  this  organ  was  quite  fatty.  But  in  this  case  the 
decreneration  and  enlars-ement  of  the  liver  were  doubtless  due  to 
the  tubercular  disease. 

In  most  of  the  cases  the  liver  was  examined  microscopically, 
and  the  only  fact  worthy  of  note  observed  was  the  variable 
amount  of  fatty  matter.  Sometimes  it  was  in  excess,  sometimes 
in  moderate  quantity  or  rather  deficient,  and  sometimes  in  greater 
amount  in  one  portion  of  the  organ  than  in  another. 

The  prevalent  belief,  then,  that  the  liver  is  greatly  aifected  in 
the  summer  epidemic  of  entero-colitis,  receives  no  corroboration 
from  the  inspection  of  this  organ.  The  only  pathological  state  (if 
it  be  such)  observed  in  it  relates  to  the  amount  of  oily  matter,  and 
this  obviously  requires  no  special  treatment. 

The  cutaneous  aflections  complicating  entero-colitis  have  already 
been  alluded  to. 

Frequently,  at  post-mortem  examinations  of  infants  who  have 
died  of  entero-colitis,  intussusceptions  are  found  in  the  small 
intestines.  These  probably  in  general  occur  at  the  moment  of,  or 
not  long  before,  death,  but  I  have  in  a  few  instances  found  intus- 
susceptions which  sustained  the  weight  of  two  feet  or  more  of 
intestine  without  being  reduced,  and  which,  from  being  in  their 
interior  more  vascular  than  the  contiguous  membrane  either  above 
or  below,  probably  occurred  some  hours,  possibly  days,  before  death, 
but,  being  sufficiently  pervious  to  allow  the  food  to  pass,  symptoms 
of  obstruction  were  absent. 

It  has  been  said,  in  speaking  of  the  symptoms,  that  a  cough  is 
common  in  the  advanced  stages  of  entero-colitis,  particularly  when 
the  disease  is  protracted  for  weeks  or  months.  From  the  great 
emaciation  and  the  character  of  the  cough,  the  physician  as  well 
as  friends  is  very  apt  to  suspect  the  presence  of  tubercles.  In  the 
eighty-two  examinations,  however,  which  I  have  made  of  entero- 
colitis of  the  summer  season,  in  many  of  which  emaciation  was 
extreme,  there  were  tubercles  in  only  one  case.  The  cough  was 
found  to  be  due  to  solidification  of  the  posterior  and  dependent 
portion  of  one  or  both  lungs.  The  exact  pathological  character  of 
this  solidification  of  lung  (hypostatic  pneumonitis)  is  treated  of  in 
our  remarks  on  diseases  of  the  respiratory  organs. 

In  the  cases  of  entero-colitis  which  Avere  complicated  with  this 
state  of  the  lungs,  I  have  not  usually  found  enough  of  the  lung 
tissue  involved  to  make  any  perceptible  difference  in  the  sound 
on  percussion.  Its  extent  of  solidification  was  sometimes  not 
more  than  two  or  three  lines,  and  frequently  not  more  than  a 


DIAGNOSIS  —  PROGNOSIS.  609 

quarter  to  lifilf  an  incli  in  an  antero-posterior  direction,  although 
it  embraced  nearly  or  quite  the  entire  posterior  surface  of  the  lung. 

The  state  of  the  brain  in  the  entero-colitis  of  inftincy  is  inter- 
esting to  the  pathologist.  When  the  disease  is  protracted,  this 
organ  wastes  like  the  body  and  limbs.  In  the  young  infant,  in 
whom  the  cranial  bones  are  still  ununited,  the  occipital  and  some- 
times the  frontal  become  depressed  in  proportion  to  the  loss  of 
brain  substance,  so  that  the  cranium  is  quite  uneven.  In  older 
children  with  the  cranial  bones  consolidated,  serous  effusion  occurs 
according  to  the  degree  of  waste,  thus  preserving  the  size  of  the 
encephalon.  The  effusion  is  chiefly  external  to  the  brain,  extend- 
ing on  each  side  over  the  convolutions  from  the  base  to  the  vertex. 
The  quantity  of  serum  varies  from  one  or  two  drachms  to  an 
ounce,  or  even  more.  The  serous  effusion  is  associated  with 
passive  congestion  of  the  cerebral  vessels  and  cranial  sinuses. 

Diagnosis. — The  only  disease  with  which  infantile  inflammation 
of  the  intestines  is  likely  to  be  confounded  is  non-inflammator}- 
diarrhoea.  The  means  of  diagnosticating  the  one  from  the  other 
are  indeed  uncertain.  There  is  no  pathognomonic  sign  or  symp- 
tom, in  the  majority  of  cases,  in  either  affection.  Occasionally  we 
are  able  to  diagnosticate  colitis  from  the  presence  in  the  stools  of 
mucus  or  mucus  tinged  with  blood.  Abdominal  tenderness,  which 
in  the  adult  is  so  important  a  diagnostic  symptom  of  intestinal 
inflammation,  is  generally  absent  in  the  infant,  or,  if  present,  is 
not  easily  ascertained.  The  presence  of  fever  and  the  severity 
and  persistence  of  the  symptoms,  render  it  probable  that  the  disease 
is  inflammatory. 

In  general  I  have  found  that,  if  diarrhoea  continued  more  than 
a  week  in  the  summer  season,  it  had  become  inflammatory.  Some- 
times, however,  as  I  have  in  at  least  three  cases  seen,  and  as  the 
French  physicians  state,  diarrhoea  may  continue  for  a  much  longer 
time,  attended  by  extreme  emaciation  and  terminating  fatally, 
and  yet  at  the  post-mortem  examination  no  lesion  of  the  intestines 
be  found,  except  a  tumefied  state  of  the  intestinal  glands.  Practi- 
cally it  matters  little  whether  we  ascertain  the  inflammatory  or 
non-inflammatory  character  of  the  disease,  as  we  determine  the 
proper  mode  of  treatment  from  the  symptoms  and  general  condi- 
tion of  the  patient. 

Prognosis. — I  have  said  that  intestinal  inflammation  is  one  of 

the  most  fatal  of  infantile  diseases.     Still  it  is  possible,  by  proper 

hygienic  measures  and  a  judicious  selection  and  use  of  medicines, 

to  save  a  large  proportion  of  those  aftected.      Entero-colitis  and 

89 


610  INTESTINAL    INFLAMMATION    OF    INFANCY. 

most  of  its  complications  are  of  such  a  nature  that  we  may  have 
reasonable  hope  that  the  infant  will  recover  if  all  measures  cal- 
culated to  control  the  disease  are  employed.  Many  do  recover  from 
a  state  of  emaciation  and  feebleness  which,  occurring  in  any  other 
pathological  state,  would  be  almost  necessarily  fatal.  The  most 
unfavorable  symptoms  in  this  disease,  except  those  due  to  extreme 
prostration  or  collapse,  arise  from  the  state  of  the  brain.  Rolling 
the  head,  squinting,  feeble  action  of  the  pupils,  spasmodic  or  ir- 
regular movements  of  the  limbs,  indicate  the  near  approach  of 
death.  There  are  many  facts  which  should  be  taken  into  con- 
sideration in  making  a  prognosis.  The  age  of  the  infant,  the 
time  in  the  year,  the  surroundings,  especially  in  reference  to  the 
impurity  of  the  atmosphere,  are  to  be  considered,  as  well  as  the 
present  state  of  the   patient. 

Intestinal  inflammation  of  infancy  might,  in  many  instances,  be 
prevented  by  judicious  measures.  Especially  is  it  preventable  in 
those  cases  in  which  the  exciting  cause  is  dietetic.  The  reader  is 
referred  to  the  chapters  on  weaning  and  artificial  feeding,  for  facts 
in  reference  to  this  matter.  Unfortunately,  however,  the  physician 
is  not  generally  consulted  in  regard  to  the  alimentation  of  the 
infant,  or  the  time  and  manner  of  weaning,  or  other  important 
matters  of  regimen,  until  diarrhoea,  inflammatory  or  non-inflam- 
matory, is  established;  his  purpose  is  then  not  to  prevent,  but  to 
cure. 

Tkeatment.  Begimenal  Measures. — Intestinal  inflammation  of 
infancy  requires  somewhat  difierent  treatment,  according  to  the 
cause,  as  well  as  the  condition  of  the  patient.  If  it  occur  in  an 
infant  of  previous  good  health,  and  from  exposure  to  cold,  its  diet 
should  at  first  be  reduced.  If  it  be  nursing,  it  should  take  the 
breast  less  frequently.  It  will  then  receive  less  nutriment,  not 
only  in  consequence  of  the  longer  interval  between  the  times  of 
nursing,  but  because  the  milk  remaining  in  the  breast  becomes 
more  watery  and  less  nutritious.  If  thirsty,  it  may  take  a  little 
light  barley-water  or  gum-water.  If  the  infant  be  weaned,  a 
corresponding  reduction  in  its  nutriment  should  be  made. 

These  cases  require  mild  counter-irritation  over  the  abdomen, 
followed  by  emollient  poultices,  or  warm  water  applications  covered 
with  oil  silk.  After  the  acute  stage  has  passed,  more  frequent 
nursing  and  more  nutritious  diet  should  be  allowed.  Often  the 
alcoholic  stimulants  in  barley-water,  and  sometimes  the  animal 
broths,  are  required  in  this  stage  of  the  disease.  Exhaustion  should 
be  guarded  against  in  the  infant. 


TREATMENT.  611 

As  one  of  the  chief  causes  of  intestinal  inflammation  of  infancy, 
particularly  in  the  city,  is  the  use  of  food  which  does  not  agree 
with  the  digestive  system,  feeble  and  easily  deranged  at  that  early 
age,  attention  should  be  directed,  in  those  cases  in  which  the  dis- 
ease does  not  seem  to  be  due  to  the  impression  of  cold,  not  only 
to  the  nature  of  the  food,  but  to  the  mode  of  its  preparation  and 
the  quantity  given.  To  the  young  infant  with  entero-colitis,  no 
food  is  so  easily  digested,  and  is  therefore  so  suitable,  as  human 
milk.  The  bottle-fed  infant,  under  the  age  of  twelve  months, 
remaining  in  the  city  in  the  summer  season,  and  aifected  with 
intestinal  inflammation,  cannot  in  general  be  successfully  treated 
unless  it  is  provided  with  a  wet-nurse.  Frequently,  when  the 
diarrhoea  continues  in  spite  of  all  other  measures  hygienic  and 
medicinal,  the  infant  begins  at  once  to  improve  by  the  employment 
of  a  wet-nurse.  It  is  sometimes  really  surprising  to  observe  as  a 
consequence  of  this  measure  the  rapid  and  complete  restoration  to 
health  from  a  state  of  extreme  emaciation. 

In  certain  cases  the  breast-milk,  either  of  the  mother  or  wet- 
nurse,  disagrees  with  the  infant,  and  its  use  aggravates  the  intes- 
tinal disease.  In  the  country,  or  in  the  city  in  the  cool  months, 
weaning  may  be  proper  under  such  circumstances.  Certainly 
weaning  or  the  employment  of  another  wet-nurse  is  required.  In 
the  city  in  the  summer  months,  for  reasons  elsewhere  fully  stated, 
weaning  is  a  very  injudicious  if  not  fatal  measure,  and,  if  the 
entero-colitis  is  aggravated  by  the  character  of  the  mother's  milk, 
a  wet-nurse  should  be  engaged.  If  the  breast-milk  is  susjDected 
as  the  cause  or  one  cause  of  the  infant's  sickness,  it  should  be 
examined  by  the  microscope,  before  a  change  in  diet  or  in  nursing 
is  recommended.  It  has  been  ascertained  by  the  microscoj)e,  that 
the  elements  of  colostrum  which  have  a  purgative  effect  may  return 
at  any  period  of  lactation. 

If  the  mother's  milk  disagrees,  and  a  wet-nurse  for  any  reason  is 
not  employed,  it  is  then  necessary  to  recommend  a  diet  which  will 
be  the  best  possible  substitute  for  the  natural  aliment.  Well- 
boiled  barley-water,  or  Ridge's  food,  the  basis  of  which  is  wheat- 
flour,  the  upper  third  of  cow's  milk  when  it  has  stood  two  or  three 
hours,  the  expressed  juice  of  lean  beefsteak  slightly  roasted,  and 
scraped  raw  beef,  may  be  mentioned  among  the  articles  of  diet 
which  I  have  found  useful  in  these  cases.  For  facts  in  reference 
to  artificial  feeding,  and  for  dietary  formulae,  the  reader  is  referred 
to  chapters  relating  to  the  diet  of  infancy. 

Attention  to  the  diet  of  infants  affected?  with  intestinal  inflam- 


612  INTESTINAL    INFLAMMATION    OF    INFANCY. 

mation  is  obviously  of  the  utmost  importance,  but  oue  chief  cause 
of  the  disease,  especially  of  tlie  great  summer  epidemic  of  the 
cities,  we  have  seen  to  be  atmospheric.  This  requires  attention 
on  the  part  of  the  practitioner  to  a  different  matter  in  the  hygi- 
enic management  of  these  cases,  namely,  the  state  of  the  air  which 
the  infant  breathes.  In  the  cool  months,  the  atmosphere  is  more 
pure  than  in  the  summer  months,  as  it  contains  less  of  those 
noxious  gases  which  arise  from  decaying  animal  and  vegetable 
substances.  In  those  months,  then,  in  which  the  weather  is  such 
that  there  is  no  decomposition  of  organic  matter,  the  atmospheric 
cause  of  entero-colitis  is  not  operative,  and  little  is  gained  for  the 
patient  by  change  of  locality.  But  in  the  summer  season  one  of 
the  most  important  conditions  of  successful  treatment  of  this  and 
the  other  diarrhoeal  maladies  of  infancy  is  the  removal  of  patients 
from  an  impure  to  a  pure  atmosphere.  Physicians  of  experience 
all  agree  in  the  choice  of  elevated  localities,  containing  a  sparse 
population,  and  remote  from  the  sea-shore.  Many  are  the  in- 
stances every  summer  in  this  city  of  infants  removed  to  the 
country  with  intestinal  inflammation,  with  features  haggard  and 
shrunken,  with  limbs  shrivelled  and  skin  lying  in  folds,  too  weak 
to  raise  or  at  least  hold  their  heads  from  the  pillow,  vomiting 
nearly  all  the  nutriment  taken,  with  stools  frequent  and  thin,  re- 
sulting in  great  measure  from  molecular  disintegration  of  the 
tissues,  presenting  indeed  an  appearance  seldom  seen  in  any  other 
disease  except  in  the  last  stages  of  phthisis,  and  returning  in  late 
autumn,  with  the  cheerfulness,  vigor,  and  rotundity  of  health.  The 
localities  usually  preferred  by  the  physicians  of  this  city  are  the 
^elevated  portions  of  'New  Jersey  and  Eastern  Pennsylvania,  the 
Highlands  of  the  Hudson,  the  central  and  the  northern  parts  of 
New  York  State,  and  Northern  New  England.  Taken  to  a  salu- 
brious locality,  the  infant  will  soon  begin  to  improve  after  it  has 
recovered  from  the  fatigue  of  travelling,  unless  the  case  is  incu- 
rable. 

Sometimes  parents,  not  noticing  the  immediate  improvement 
which  they  had  been  led  to  expect,  return  to  the  city  without 
giving  the  country  fair  trial,  and  the  life  of  the  infant  is  almost 
necessarily  sacrificed.  Eeturned  to  the  foul  air  of  the  city  while 
the  weather  is  still  warm,  it  sinks  rapidly  from  an  aggravation 
of  the  malady.  Dr.  James  Jackson  recommends,  if  the  infant  do 
not  improve  where  it  is  taken,  that  it  should  be  conveyed  to 
another  locality.  This  is  good  advice,  provided  the  selection  be 
made  of  a  place  elevated,  remote  from  the  sea-shore,  and  having  a 


TREATMENT.  613 

8[)iirso  population.  The  infant,  althougli  it  has  recovered,  should 
not  be  brous-ht  back  while  the  weather  is  still  warm.  One  attack 
of  the  disease  does  not  diminish  but  increases  the  liability  to  a 
second  seizure. 

If  the  situation  of  the  family  is  such  that  it  is  not  practicable 
to  take  the  infant  to  the  country,  and  such  cases  are  frequent 
among  the  poor,  it  should  be  kept  much  of  the  time  in  the  open 
air;  it  is  a  common  practice  in  this  city  to  take  such  patients  in 
the  daytime  to  the  sea-shore,  or  upon  ferry  boats.  Dr.  E.  H.  Parker 
says:  "Many  of  my  patients  are  sent  to  the  ferries  to  cross  them, 
so  that  the  cool  fresh  sea  breeze  may  fan  them,  and  it  acts  some- 
times like  magic,  to  raise  their  drooping  heads."  I  have  not 
observed  such  marked  benefit  in  these  cases  from  the  sea  breeze  as 
from  the  air  of  elevated  localities,  which  can  generally  be  found  in 
the  vicinity  of  cities,  and  are  easily  accessible.^ 

Medicinal  Treatment. — Someti^jes  it  is  proper  to  commence  treat- 
ment by  the  employment  of  a  gentle  purgative,  particularly  when 
the  disease  commences  abruptly  from  a  state  of  previous  good 
health.  It  is  then  frequently  caused  by  exposure  to  cold,  or  more 
rarely  by  some  indigestible  and  highly  irritating  substance  in  the 
intestines.  In  such  patients,  there  is  often  a  full  habit.  The 
pulse  is  strong  and  quick,  the  heat  of  surface  great,  the  face 
perhaps  flushed,  the  stools  sometimes  slimy  and  bloody,  sometimes 
green  or  brown.  It  is  proper  and  often  serviceable,  when  there  is 
this  commencement  of  the  affection,  to  give  a  single  dose  of  castor 
oil  or  syrup  of  rhubarb.  Any  indigestible  substance,  if  present,  is 
removed  from  the  intestine,  and  opiates  or  other  remedies  designed 
to  control  the  disease  may  then  be  more  successfully  employed. 
Such  cases  occur  in  the  winter  not  less  than  in  the  summer,  and 
in  all  localities,  rural  as  well  as  in  the  city.  But  the  summer 
epidemics  of  intestinal  inflammation  in  the  cities  do  not  in  general 
require  such  preliminary  treatment.  Diarrhoea,  moderate,  perhaps, 
has  already  continued  for  a  time  when  the  physician  is  called,  and 
no  irritating  substance  remains  except  the  acid,  which  is  abundantly 
generated  in  the  intestine  in  this  disease,  and  which  we  have  a 
means  of  removing  without  purgation.  Preliminary  treatment 
having  been  employed  or  not,  according  to  the  nature  of  the  attack 

'  The  remarks  made  in  reference  to  the  use  of  pepsin  in  indigestion  and  non- 
inflammatory diarrhoea  apply  also  to  those  cases  of  inflammatory  diarrhoea  which 
are  due  to  feebleness  of  the  digestive  function. 


614  INTESTINAL    INFLAMMATION    OF    INFANCY. 

and  condition  of  the  patient,  remedies  calculated  to  arrest  the 
inflammation  should  then  be  prescribed. 

The  medicines  which  should  be  employed  are  chiefly  of  three 
kinds,  namely,  alkalies,  opiates,  and  astringents ;  sometimes  one 
or  two  kinds  only,  and  sometimes  all  three,  according  to  the  cha- 
racter of  the  evacuations.  The  antacid  treatment  is,  of  course, 
required  in  those  numerous  cases  in  which  the  stools  are  acid,  and 
there  is  no  better  alkaline  remedy  for  the  diarrhoea  in  this  disease 
than  the  preparations  of  chalk.  The  creta  prseparata  of  the  phar- 
macopoeias, in  doses  of  two  or  three  grains  to  a  child  one  year  old, 
or  the  mistura  cretse  in  teaspoonful  doses,  are  eligible  preparations, 
and  are  commonly  employed.  These  medicines  should  be  repeated 
in  two  hours,  or  a  longer  time,  according  to  the  state  of  the  patient. 
Chalk  given  for  a  moderate  period  is  innocuous,  and  may  be  ad- 
ministered to  the  youngest  child. 

In  Europe  the  crab's  eye  is  much  used,  and  it  is  stated  that  it 
is  sometimes  eftectual  in  controlling  the  disease,  when  the  chalk 
fails.     The  following  is  a  formula  recommended  by  Bouchut: — 

K-  Ocul.  cancror.  pulv.  gr.  x  ; 
Aq.  foeniculi, 
Syr.  rhei,  aa  ^ss.  M. 

One  teaspoonful  every  hour.  In  this  country  the  same  antacid 
has  been  also  employed,  though  less  frequently  than  the  prepara- 
tions of  chalk.  J.  F.  Meigs,  of  Philadelphia,  prescribes  it  as  fol- 
lows:— 

R.  Ocul.  cancror.  pulv.  5j  ; 
Acacije  pulv.  5'j  ; 
Sacch.  alb.  9j ; 
Aq.  fontis, 
Aq.  ciunamom.,  aa  ^jss.  M. 

A  teaspoonful  four,  five,  or  six  times  daily.  By  means  of  this 
alkali  alone,  aided  by  proper  hygienic  measures,  the  disease  is 
sometimes  arrested,  but,  unless  circumstances  are  favorable  and 
the  case  is  mild,  other  medicines  are  required. 

Opium  is  used  by  most  practitioners  in  the  treatment  of  intes- 
tinal inflammations  of  infancy.  Either  as  a  main  remedy  or  ad- 
juvant it  is  employed,  and  properly,  in  nearly  all  severe  cases.  For 
a  young  infant  paregoric  is  an  eligible  preparation  of  opium.  For 
the  age  of  one  month,  the  dose  is  three  to  five  drops ;  for  the  age 
of  six  months,  ten  to  twelve  drops,  repeated  in  three  hours  or  a 
longer  time,  according  to  the  state  of  the  patient.  After  the  age 
of  six  months,  the  stronger  preparations  of  opium  are  more  fre- 


TREATMENT.  615 

quently  used.  At  the  age  of  one  year,  the  liq.  opii  compositus  or 
tincture  opii  may  bo  given  in  doses  of  one  to  two  drops,  Dover's 
powder  is  also  an  excellent  medicine  in  this  disease,  given  in  doses 
of  three-fourths  of  a  grain  to  an  infant  one  year  old. 

Opium  is,  however,  in  general  best  given  in  mixtures  which  will 
be  mentioned  hereafter.  It  quiets  the  action  of  the  bowels,  and 
diminishes  the  number  of  evacuations.  It  is  contra-indicated  or 
should  be  used  with  caution  if  cerebral  symptoms  are  present. 
Sometimes  in  the  commencement  of  the  disease,  if  there  is  much 
febrile  reaction,  the  patient  may  be  drowsy  and  in  danger  of  con- 
vulsions. Then  opiates  should  be  given  cautiously  or  withheld. 
Also  in  the  advanced  stages  of  this  disease,  when,  perhaps,  there 
is  more  or  less  serous  effusion  in  the  cranial  cavity,  opium  should 
be  cautiously  used,  as  it  might  tend  to  produce  that  fatal  stupor, 
in  which  the  unfavorable  cases  are  apt  to  terminate. 

Astringents  are  required  when  the  evacuations  are  thin  and  fre- 
quent, and  are  not  sufficiently  controlled  by  the  remedies  already 
mentioned.  Those  of  a  vegetable  nature  are  usually  preferred,  as 
they  are  compatible  with  chalk,  and  may  be  given  in  combination 
with  it.  The  astringents  commonly  used  are,  catechu,  kino,  kra- 
meria,  tannic  and  gallic  acids.  Logwood  and  blackberry  roots  are 
also  occasionally  employed. 

If  the  disease  become  chronic,  nitrate  of  silver  and  acetate  of 
lead  are  sometimes  useful.  Astringents  should  not  be  given  if  the 
stools  are  scanty  and  consistent  though  frequent,  nor  should  they 
be  employed  if  the  evacuations  are  muco-sanguinolent,  as  in  the 
dysentery  of  the  adult. 

I  will  now  mention  the  various  combinations  of  medicines  which 
have  been  found  the  most  useful  in  intestinal  inflammation. 

In  all  those  cases  in  which  the  evacuations  consist  chiefly  of 
mucus,  or  mucus  and  blood,  and  in  all  recent  cases  in  which  the 
evacuations  are  scanty,  and  there  is  considerable  fever,  one  of  the 
best  formulae  is  the  following,  which  is  similar  to  that  recom- 
mended by  Dr.  West: — 

^.  Tinct.  opii  gtt.  xij ; 
Pulv,  gum  acac, 
Pulv.  sacch.  alb.,  aa  3j  ; 
01.  ricini  3j  to  3ij  ; 
Aq.  cinnamom.  5Jss.  M. 

One  teaspoonful  every  three  hours.  In  these  cases,  also,  Dover's 
powder,  given  at  the  same  interval  with  half  a  teaspoonful  of 


616  INTESTINAL    INFLAMMATION    OF    INFANCY. 

castor  oil  once  or  twice  daily,  will  have  good  efiect  in  controlling 
the  disease. 

In  the  more  common  forms  of  infantile  entero-colitis,  in  which 
the  stools  are  green,  or  brown,  or  yellow,  and  are  watery  and  fre- 
quent, one  of  the  best  medicines  is  the  pulv.  cret.  comp.  c.  opio, 
combining,  as  it  does,  alkali,  opiate,  and  astringent. 

Three  grains  may  be  given  every  two  or  three  hours  to  a  child 
one  year  old,  till  the  diarrhoea  is  controlled.  For  young  infants 
paregoric,  catechu,  and  chalk,  as  recommended  in  the  treatment  of 
non-inflammatory  diarrhoea,  is  a  useful  mixture.  Laudanum  or 
liq.  opii  compos,  in  proper  quantity  may  be  substituted  in  place  of 
the  paregoric,  and  kino  or  krameria  in  place  of  the  catechu. 

Gallic  or  tannic  acid  is  sometimes  administered  with  Dover's 
powder,  or  with  the  compound  powder  of  chalk  and  opium,  but 
given  in  this  way  it  is  nauseating  and  apt  to  be  vomited.  If  the 
evacuations  are  not  frequent  or  watery,  the  opiate  and  chalk 
mixture  may  be  prescribed  without  the  astringent  with  a  good 
effect. 

I  do  not  know  that  any  benefit  is  gained  in  intestinal  inflam- 
mation of  the  infant  by  the  use  of  mercurials,  and  in  many  cases 
certainly  much  harm  would  result.  They  are  not  now  commonly 
prescribed  in  the  enteritis  or  colitis  of  adults,  and  there  is  no 
lesion  in  infantile  entero-colitis,  either  as  regards  the  liver  or 
intestines,  which  requires  their  administration.  In  the  choleriform 
diarrhoea,  which  sometimes  precedes  intestinal  inflammation,  the 
use  for  a  day  or  two  of  small  doses  of  calomel  or  hydrarg.  cum  cret. 
is  thought  by  some  judicious  practitioners  to  be  of  service,  but, 
when  it  has  appeared  to  be  beneficial  in  intestinal  inflammation, 
the  good  effect  is  probably  due  chiefly  to  the  opium  which  is 
administered  with  the  mercurial. 

Often  the  disease  continues,  notwithstanding  the  use  of  the 
above  remedies,  or  if  temporarily  relieved,  the  causes  still  opera- 
ting, it  returns.  In  these  protracted  cases,  attended  perhaps  with 
more  or  less  ulceration  of  the  mucous  membrane,  the  mineral 
astringents  may  be  prescribed.  Acetate  of  lead  may  be  given  in 
doses  of  one-fourth  of  a  grain  to  an  infant  one  year  old.  Nitrate 
of  silver  is,  however,  more  frequently  prescribed  in  EurojDC,  espe- 
cially on  the  continent.  It  may  be  given  in  doses  of  one-twentieth 
to  one-twelfth  of  a  grain  in  a  little  mucilage  or  simple  syrup. 

Enemata. — These  are  of  great  service  in  many  cases  of  intestinal 
inflammation.  At  any  stage  of  the  disease,  when  the  stomach  is 
irritable  and  medicines  are  not  retained,  they  may  be  advanta- 


TREATMENT.  617 

geously  employed.  Laudanum  especially  is  often  giveii  in  tliis 
way  to  the  infant  with  great  benefit.  It  may  be  prescribed  mixed 
with  a  little  starch  water,  and  the  best  instrument  for  administer- 
ing it  is  a  small  glass  or  gutta-percha  syringe,  the  nurse  retaining 
the  enema  for  a  time  by  means  of  a  compress.  Beck,  in  his  Infant 
Therapeutics^  advises  to  give  by  injection  twice  as  much  of  the 
opiate  as  would  be  administered  by  the  mouth.  A  somewhat 
larger  proportion  may,  however,  be  safely  employed.  Astringents 
may  also-  be  given  by  enema.  Bouchut,  speaking  of  these  thera- 
peutic agents,  says :  "All  these  substances  may  be  given  as  enemata, 
composed  of  three  to  six  ounces  of  the  vehicle  holding  in  solution 
seven  to  ten  grains  of  the  extract  of  rhatany  or  monesia.  If  tannin 
is  used,  it  should  be  in  the  dose  of  four  to  seven  grains.  In  the 
same  way  and  for  the  same  end,  fifteen  to  thirty  grains  of  alum,  or, 
better  still,  less  than  one  grain  of  the  nitrate  of  silver.  These  last 
enemata  are  daily  employed  at  the  E'ecker  Hospital.  If  their  use 
is  not  constantly  followed  by  success,  there  always  results,  at  least, 
a  decided  amelioration  quite  capable  of  dissipating  the  objections 
raised  against  their  employment," 

Since  the  inflammation  is  ordinarily  most  intense  in  the  descend- 
ing colon,  and  is  sometimes  confined  to  this  portion  of  the  digestive 
tube,  benefit  results  in  certain  obstinate  cases  from  the  injection 
into  the  rectum  of  a  solution  of  nitrate  of  silver  in  warm  distilled 
water  in  the  proportion  of  one  grain  to  six  or  eight  ounces.  A 
little  laudanum  may  be  added.  This  treatment  has  been  employed 
in  the  ]S"ursery  and  Child's  Hospital,  but  only  as  an  adjuvant  to 
remedies  administered  by  the  mouth. 

In  most  of  those  cases  of  intestinal  inflammation  which  occur 
under  the  depressing  effect  of  warm  weather,  alcoholic  stimulants 
are  required  almost  from  the  commencement  of  the  disease,  and 
their  use  is  beneficial  in  chronic  or  protracted  cases,  whatever  the 
cause  or  season.  Bourbon  whiskey  or  brandy  is  the  best  of  these 
stimulants,  and  it  should  be  given  in  small  doses,  repeated  at 
intervals  of  two  hours.  I  have  usually  ordered  three  or  four  drops 
to  an  infant  one  month  old,  and  an  additional  drop  or  two  drops 
for  each  month.  The  stimulant  is  not  only  useful  in  sustaining 
the  vital  powers,  but  it  also  aids  in  relieving  the  irritability  of 
stomach. 

The  diarrhoea  is,  in  general,  more  easily  controlled  than  the 
vomiting,  A  remedy  which  with  me  has  been  useful  in  relieving 
the  latter  symptom  is  the  neutral  mixture: — 


618  INTESTINAL    INFLAMMATION    OF    INFANCY. 

I^.  Potas.  bicarbonate  gr.  xxv; 
Acid,  citric,  gr.  xvij  ; 
Aq.  amygdal.  amarse  5  j  ; 
Aquae  |ij.     Misce. 

Dose,  one  teaspoonful  to  a  child  from  eight  to  twelve  months 
old,  repeated  according  to  the  nausea  or  vomiting.  The  following 
prescription  to  relieve  this  symptom,  which  is  similar  to  one  em- 
ployed in  the  Nursery  and  Child's  Hospital  of  this  city,  has  the 
desired  eiFect  in  a  certain  proportion  of  cases: — 

^.  Acid  carbolic,  gtt.  ij ; 
Aq.  calcis  3ij.     Misce. 

Dose,  one  teaspoonful  with  a  teaspoonful  of  milk,  hreast-milk  if 
the  infant  nurses,  repeated  according  to  the  symptoms.  Lime- 
water  alone  sometimes  diminishes  the  vomiting  when  there  is 
great  acidity,  hut  it  is  rendered  more  effectual  by  the  addition  of 
carbolic  acid.  Vomiting  is  frequent  in  the  summer  epidemics  of 
intestinal  inflammation  in  the  cities,  and  it  is  in  this  form  of  the 
disease,  induced  by  an  impure  atmosphere  and  an  unsuitable  diet, 
that  I  have  observed  the  greatest  benefit  from  the  above  prescrip- 
tions. When  the  inflammation  occurs  in  other  seasons,  and  is 
produced  by  other  causes,  vomiting  is  less  frequent,  and  is  more 
easily  controlled.     It  may  then  require  no  special  treatment. 

"While  I  approve  the  above  mode  of  treatment,  which  is  re- 
printed from  the  first  edition,  more  recent  experience,  and  es- 
pecially observations  made  in  the  large  class  of  children's  diseases 
in  the  Out-door  Department  at  Bellevue,  convince  me  that  the 
subnitrate  of  bismuth  is  a  valuable  remedy  not  only  for  this 
disease,  but  also  for  cholera  i'nfantum,  and  one  which  is  appropriate 
in  most  cases.  It  has,  indeed,  long  been  used  in  the  diarrhceal 
affections  of  infancy,  but  in  doses  much  too  small.  Its  effect  is  be- 
lieved to  be  entirely  local,  namely  upon  the  gastro-intestinal  surface 
and  its  secretions.  It  undergoes  or  effects  some  chemical  cha,nge, 
for  the  stools  after  its  use  become  dark,  and  at  the  same  time  more 
consistent.  While  it  diminishes  the  frequency  of  the  evacuations, 
it  is  at  the  same  time  one  of  the  most  efficient  antiemetics.  The 
following  formula  is  for  an  infant  one  year  old: — 

K.  Bismuth,  subnit.  5j  ; 

Pulv.  cret.  comp.  c.  opii  5ss.     Misce. 
Divid.  in  chart.  No.  x.     One  powder  every  three  hours. 

I  believe  that  this  is  the  best  remedy  that  can  be  prescribed  for 
the  epidemic  entero-colitis  of  the  summer  months  in  the  cities,  in 


TREATMENT.  619 

which  disease  there  is  ordinarily  great  irritahility  of  the  stomach. 
It  is  readily  administered  mixed  with  a  little  sugar  and  moistened. 
It  is  useful  in  recent  as  well  as  protracted  cases.  If  there  is  no 
decided  irritability  of  stomach  or  acidity  of  the  stools,  Dover's 
powder  may  be  substituted  for  the  powder  of  chalk  and  opium, 
and  it  is  preferable  in  those  cases  in  which  the  entcro-colitis  results 
from  taking  cold,  and  there  is  a  strong  febrile  reaction. 

"When  the  disease  is  chronic,  and  the  vital  powers  begin  to 
fail,  as  indicated  by  pallor,  more  or  less  emaciation,  and  loss  of 
strength,  the  following  is  the  best  tonic  mixture  with  which  I  am 
acquainted.  It  aids  in  restraining  the  diarrhoea,  while  it  increases 
the  appetite  and  strength.  It  should  not  be  prescribed  until  the 
inflammation  has  assumed  a  subacute  or  chronic  character. 

R.  Tinct.  colombse.  5iij  ; 

Liq.  ferri  nitratis  gtt.  xxiv ; 
Syr.  simplic.  giij.     Misce. 

Dose,  one  teaspoonful  every  four  hours  to  an  infant  of  one  year. 
In  the  Out-door  Department  at  Bellevue  we  commonly  give  this 
tonic  alternately  with  the  bismuth  powders. 

JExternal  Treatment. — Some  writers  recommend  depletion  in  this 
disease  by  leeches,  advice  likely  to  do  much  harm,  unless  the 
particular  cases  are  described  in  which  it  may  possibly  be  of 
service.  It  can  be  useful  only  in  those  cases  in  which  the  infant 
is  robust  and  of  full  habit,  and  the  disease  commences  suddenly 
with  decided  febrile  reaction.  Such  cases  are  oftenest  seen  with 
us  in  the  winter  season,  and  even  these  are  ordinarily  best  treated 
without  loss  of  blood.  Sinapisms  and  poultices  usually  are  suffi- 
cient as  local  measures.  In  these  cases,  also,  the  warm  mustard 
foot-bath  should  be  employed,  and  repeated  if  there  is  restlessness 
or  cerebral  symptoms. 

In  all  forms  of  intestinal  inflammation  in  infancy  and  in  all  its 
stages,  mild  counter-irritation  over  the  abdomen  is  often  useful, 
but  vesication,  by  increasing  the  restlessness  of  the  infant  and 
reducing  its  strength,  without  materially  modifying  the  severity 
or  duration  of  the  disease,  does  more  harm  than  good.  It  is  not 
to  be  thought  of  as  a  remedial  measure.  I  have  known  a  trouble- 
some sore  continuing  till  death,  and  probably  hastening  this  result, 
to  occur  from  this  treatment.  Poultices  or  fomentations  over  the 
abdomen  are  sometimes  beneficial,  especially  those  of  a  mildly 
irritating  nature.  A  poultice  of  powdered  cloves,  cinnamon,  and 
ginger,  or  of  linseed  meal  to  which  a  little  mustard  is  added,  may 


G20  ENTERITIS    AND    COLITIS    IN    CHILDHOOD. 

be  employed,  or,  better  than  either,  a  linseed  poultice  spread  thin, 
under  which  a  single  layer  of  muslin  is  placed,  saturated  with 
tincture  of  camphor,  and  over  both  oil  silk.  In  the  entero-colitis 
of  infants,  occurring  in  the  cool  months,  and  due  to  exposure  to 
cold,  this  treatment  is  especially  useful.  In  the  epidemic  entero- 
colitis of  the  summer  months,  which  may  be  aggravated  by 
heat,  treatment  by  poultices  may  be  injudicious,  but  in  such  cases 
it  is  proper  to  produce  moderate  redness  over  the  abdomen  by 
temporary  applications. 

Some  physicians  believe  that  dentition  is  a  cause  of  infantile 
entero-colitis,  and  advocate  lancing  the  gums  if  they  are  found 
swollen.  In  my  opinion,  this  treatment,  in  genuine  inflammation, 
is  opposed  by  both  reason  and  experience. 


CHAPTER    IX. 

ENTERITIS  AND  COLITIS  IN  CHILDHOOD. 

Intestinal  inflammation  in  childhood  difiiers  materially  from 
the  form  or  type  which  it  commonly  presents  in  infancy.  Its 
causes,  symptoms,  and  extent  differ  in  important  particulars  in  the 
two  periods.  In  childhood  there  is  not  ordinarily  such  extensive 
inflammation  of  the  mucous  membrane  of  the  intestines  as  we  have 
seen  is  present  in  the  majority  of  cases  in  infancy,  and  it  may, 
therefore,  be  properly  treated  as  two  diseases,  according  to  the  seat 
of  the  morbid  process,  namely,  enteritis  and  colitis.  Both  these 
affections  in  the  child  resemble  so  closely  the  form  which  they 
exhibit  in  adult  life,  that  no  extended  description  is  needed  in  this 
connection. 

Causes. — These  are  vicissitudes  of  temperature,  especially  sud- 
den change  from  warm  to  cold,  which  checks  the  perspiration,  and 
causes  a  determination  of  blood  from  the  surface  to  the  viscera. 
These  inflammations  are  also  caused  sometimes  by  irritating  sub- 
stances in  the  intestines.  I  have  known  faecal  accumulations  as 
well  as  worms  to  produce  severe  dysentery  in  the  child,  accom- 
panied by  the  characteristic  tenesmus  and  muco-sanguineous  stools, 
and  ceasing  as  soon  as  the  offending  substances  were  expelled. 
The  use  of  unripe  or  stale  vegetables,  if  there  is  a  strong  predis- 
position to  mucous  inflammation,  may  be  a  sufficient  cause,  and 


SYMPTOMS.  G21 

some  of  the  most  dans-eroiis  cases  are  due  to  the  accumulation  in 
the  intestines  of  seeds  and  the  parenchyma  of  fruits.  But  the 
most  common  cause  is  that  mentioned,  namely,  sudden  exposure 
to  cold  when  the  body  is  heated,  a  danger  to  which  children  are 
especially  liable,  on  account  of  the  easy  disturbance  of  the  circula- 
tory system  in  them,  and  their  heedless  exposure  of  themselves, 
unless  incessantly  watched. 

Enteritis  and  colitis  are  also  frequently  secondary  diseases.  They 
occur  in  children  as  complications  or  sequelae  of  the  eruptive  fevers, 
especially  measles. 

Symptoms. — The  alvine  discharges  in  enteritis  and  colitis  in 
childhood  are  such  as  occur  in  these  diseases  at  a  more  advanced 
age.  In  enteritis  they  are  thin  and  of  the  natural  color,  or  occa- 
sionally green;  in  colitis  they  are  more  consistent  than  in  enteritis, 
and  are  largely  muco-sanguineous.  Sometimes  in  enteritis,  if  the 
inflammation  is  not  intense,  the  diarrhoea  is  slow  in  appearing,  or 
it  may  be  slight,  so  as  not  to  attract  special  attention.  The  dis- 
ease may  then  resemble  remittent  fever,  for  which  it  is  at  times 
mistaken.  The  upper  part  of  the  small  intestines  is  less  frequently 
affected  than  the  lower.  If  there  is  duodenitis,  the  flow  of  bile  is 
occasionally  impeded  from  tumefaction  at  the  mouth  of  the  common 
bile-duct,  and  the  icteric  hue  appears.  In  both  enteritis  and  colitis 
there  is  abdominal  tenderness,  with  more  or  less  constant  pain  if 
the  disease  is  severe,  and  in  colitis,  tormina,  and  tenesmus.  The 
pulse  is  accelerated,  the  heat  of  surface  augmented,  the  face 
flushed,  and,  except  in  mild  cases,  indicative  of  suftering.  In 
many  children  at  the  commencement  of  the  inflammation  the 
nervous  system  is  profoundly  affected,  as  indicated  by  headache, 
stupor,  twitching  of  the  limbs,  and  sometimes  by  convulsions.  The 
chief  danger  at  the  commencement  of  the  disease  is,  indeed,  from 
this  source.  Sometimes  there  is  irritabilitv  of  the  stomach,  and 
the  food  is  rejected,  though  much  less  frequently  than  in  the 
intestinal  inflammation  of  infancy.  Anorexia  and  thirst  are  com- 
mon symptoms.  If  the  inflammation  continue,  there  is  soon  per- 
ceptible emaciation,  with  loss  of  strength.  The  eyes  become 
hollow,  the  face  pale,  and  the  surface  cool.  Death  may  occur  at 
an  early  period,  the  vital  powers  succumbing  from  the  intensity 
of  the  inflammation.  In  other  cases,  the  acute  disease  ends  in  a 
subacute  or  chronic  inflammation;  the  patient  becomes  gradually 
more  reduced,  till  he  dies  in  a  state  of  extreme  emaciation,  such 
as  we  often  observe  in  the  entero-colitis  of  infancy,  or  from  this 
state  he  may  recover  by  degrees,  though  perhaps  with  an  irritable 


622  ENTERITIS    AND    COLITIS    IN    CHILDHOOD. 

state  of  the  bowels,  which  continues  for  months.  In  a  majority  of 
cases,  however,  enteritis  and  colitis  in  childhood,  if  not  neglected 
soon  begin  to  yield,  and  terminate  favorably  in  one  or  two  weeks. 

Diagnosis. — It  is  not  difficult  to  determine  the  existence  of  the 
inflammation.  This  is  indicated  by  the  fever,  abdominal  tender- 
ness, and  the  relaxed  state  of  the  bowels.  "Whether  the  disease  is 
enteritis  or  colitis  is  determined  by  the  character  of  the  stools,  the 
seat  of  the  tenderness,  and  the  presence  or  absence  of  tenesmus. 

Prognosis. — It  has  been  stated  above  that  enteritis  and  colitis 
in  children  commonly  terminate  favorably.  The  result  depends 
not  only  on  the  extent  and  severity  of  the  inflammation,  but  the 
constitution  and  previous  health.  The  inflammation  is  more  seri- 
ous when  secondary  than  when  primary.  Extensive  and  great 
tenderness  of  the  abdomen,  features  pale,  anxious,  and  indicative 
of  sufiering,  pulse  frequent  and  feeble,  should  excite  the  most 
serious  apprehensions.  Frequent  vomiting  also  denotes  a  grave 
form  of  the  disease.  Stupor,  and  especially  convulsive  movements, 
show  that  the  nervous  centres  are  afi:ected,  and  should  make  us 
guarded  in  the  prognosis.  Improvement  in  the  disease,  on  which 
to  base  a  favorable  prognosis,  is  apparent  in  the  diminution  of  the 
tenderness,  improvement  in  the  pulse  and  character  of  the  stools,  a 
more  cheerful  countenance,  and  less  disrelish  of  food. 

Treatment. — This  should  be  similar  to  that  employed  in  the 
adult.  In  enteritis  at  the  commencement  of  the  disease,  if  there 
is  reason  to  suspect  the  presence  of  any  irritating  substance  in  the 
intestines,  and  ordinarily  in  colitis,  it  is  advisable  to  commence 
treatment  by  the  use  of  some  simple  evacuant,  like  castor  oil. 
After  this  our  reliance,  so  far  as  internal  treatment  is  concerned, 
must  be  mainly  on  opiates,  or  opiates  with  diaphoretics.  One  of 
the  best  remedies  of  this  class  is  the  Dover's  powder,  which  may 
be  given  to  a  child  five  years  old  in  doses  of  three  grains  every 
three  hours.  A  corresponding  dose  of  any  of  the  other  opiates  may 
be  given,  but  with  less  sudorific  effect.  In  colitis  the  occasional 
administration  of  a  laxative  should  not  be  neglected,  if  the  stools 
are  entirely  or  mainly  muco-sanguineous.  It  should  be  employed 
so  as  to  prevent  accumulation  of  fsecal  matters  in  the  colon,  which 
would  serve  as  an  irritant  and  increase  the  inflammation.  The 
dose  should  be  small,  merely  sufficient  to  produce  a  feecal  evacua- 
tion, and  repeated  as  required,  daily  or  less  frequently.  The 
laxative  commonly  preferred  is  Rochelle  salts  or  castor  oil.  The 
physician  may  prescribe  an  opiate  mixture  containing  sufficient 
of  the  laxative  to  have  the  eft'ect  desired,  though  ordinarily  it  is 


1 
I 


TREATMENT.  023 

better  to  prescribe  the  two  separately,  so  that  the  laxative  can  be 
given  or  withheld,  according  to  circumstances,  while  the  opiate  is 
continued  more  regularly. 

When  the  stage  of  active  inflammation  has  passed,  if  there  is 
still  looseness  of  the  bowels,  astringents  should  be  employed  in 
connection  with  the  opiate.  The  tincture  of  catechu  or  kino  may 
1)0  given  with  an  equal  quantity  of  paregoric.  The  subnitrate  of 
bismuth  in  doses  of  from  Ave  to  ten  grains  in  combination  with 
Dover's  powder  or  other  opiate  will  also  be  found  useful. 

Acetate  of  lead  with  opium,  so  much  used  in  adult  cases,  is 
equally  serviceable  in  children.  One  grain  may  be  given  to  a  child 
of  five  years  with  one-third  of  a  grain  of  opium.  Injections 
properly  administered  aid  in  controlling  the  inflammation.  Those 
containing  opium  are  especially  serviceable  in  relieving  the 
tenesmus  of  dysentery.  When  the  stomach  is  irritable,  or  when  it 
is  desired  to  use  a  medicine  like  tannic  acid,  which  is  unpleasant 
to  the  taste,  it  is  often  best  to  administer  it  in  the  form  of  enemata 
or  suppositories. 

Local  treatment  is  highly  important  in  the  enteritis  and  colitis 
of  childhood.  Leeches  in  the  commencement  of  the  inflammation 
have  a  good  effect  in  moderating  its  intensity.  If  the  disease  is 
secondary,  or  there  is  scrofula  or  a  state  of  feebleness,  depletion  is 
contra-indicated. 

Apart  from  leeching,  the  local  treatment  should  consist  in  the 
use  of  emollient  applications  covered  with  oil-silk,  and  made 
sufiiciently  irritating  by  mustard  or  otherwise  to  cause  constant 
redness. 

If  there  are  symptoms  threatening  convulsions,  a  mustard  foot- 
bath repeated  occasionally  will  usually  tranquillize  the  nervous 
system  and  avert  the  danger. 

The  diet  should  be  bland  and  unirritating.  In  the  first  stages 
of  the  inflammation,  ricexor  barley-water,  or  arrowroot  boiled  in 
water,  and  similar  drinks  should  constitute  the  main  diet.  When 
the  active  inflammation  has  abated,  and  at  any  period  of  the  dis- 
ease if  there  is  a  tendency  to  prostration,  more  nourishing  food 
should  be  given.  Milk  and  animal  broths  may  then  be  allowed. 
In  cases  which  are  protracted,  or  attended  with  symptoms  of 
exhaustion,  alcoholic  stimulants  are  required. 


624  CHOLERA    INFANTUM. 


CHAPTER  X. 

CHOLERA  INFANTUM. 

Cholera  infantum,  or,  as  it  is  sometimes  called,  clioleriform 
diarrhoea,  is  a  disease  of  the  summer  months ;  and,  with  excep- 
tional cases,  of  the  cities.  It  receives  the  name  which  designates 
it  from  the  violence  of  its  symptoms,  which  closely  resemble  those 
in  Asiatic  cholera.  It  is,  however,  quite  distinct  in  its  nature, 
occurring  independently  of  the  epidemics  of  that  disease.  Post- 
mortem examinations  establish  the  fact  that  it  is  a  non-inflamma- 
tory diarrhoea,  but  on  account  of  the  violence  and  striking  character 
of  its  symptoms,  and  its  great  mortality,  it  is  proper  to  describe  it 
as  a  distinct  disease. 

I  have  elsewhere  stated  that,  as  regards  at  least  this  city,  the 
term  cholera  infantum  has  been  so  extended  as  to  embrace  a  large 
part  of  the  diarrhoeal  maladies  afl:ecting  infants  in  the  summer 
months.  Some  physicians  apply  it  even  to  mild  but  protracted 
cases  of  ordinary  non-inflammatory  or  inflammatory  diarrhoea 
occurring  in  the  season  mentioned.  I  employ  it,  and  it  should,  in 
my  opinion,  only  be  employed,  to  designate  that  form  of  infantile 
diarrhoea  in  which  there  are  frequent  watery,  perhaps  serous  stools, 
accompanied  by  vomiting  and  rapid  and  great  emaciation.  More- 
over, when  the  disease  ceases  to  be  of  this  character,  the  term 
cholera  infantum  should  no  longer  be  applied  to  it,  but  it  should 
receive  another  name  indicative  of  the  pathological  state  which 
has  supervened.  Intestinal  inflammation  frequently  succeeds 
cholera  infantum,  and  certain  writers  describe  it  as  a  stage  of  that 
disease.  Properly,  the  inflammation  should  be  regarded  as  a  dis- 
tinct afl'ection,  just  as  the  enteritis,  which  sometimes  results  from 
cholera  morbus,  is  not  considered  as  a  stage  of  that  disease,  but  as 
a  disease  in  itself. 

The  number  of  deaths  from  cholera  infantum  reported  in  our 
bills  of  mortality  is  so  large,  while  the  number  from  the  same 
disease  embraced  in  the  death  statistics  of  European  cities  is  so 
small  comparatively,  that  some  have  been  led  to  believe  that  this 
affection,  whether  termed   cholera   infantum,   or,  as   l^y  French 


CAUSES  —  SYMPTOMS.  ()25 

writers,  cholerlform  diarrlicea,  is  much  more  prevalent  and  fatal  in 
this  country  than  in  Europe,  wliereas,  were  these  terms  employed 
in  all  places  to  designate  precisely  the  same  disease,  probably  no 
great  difference  would  be  found  in  the  prevalence  of  cholera 
infantum  on  the  two  sides  of  the  Atlantic. 

Causes. — It  has  been  stated  that  cholera  infantum  prevails 
mainly  in  the  cities  and  in  the  summer  months.  Cases  occur  from 
.the  month  of  May  to  October.  Its  maximum  frequency  and 
severity  correspond  with  the  degree  of  heat,  and  it  is  therefore 
most  prevalent  in  the  months  of  July  and  August.  One  of  the 
chief  causes  of  this  disease  is,  doubtless,  residence  in  an  atmosphere 
loaded  with  noxious  vapors,  especially  gases  arising  from  animal 
and  vegetable  decomposition,  or  an  atmosphere  rendered  impure 
by  overcrowding  and  by  personal  and  domiciliary  uncleanliness. 
It  is,  therefore,  much  more  common  in  tenement-houses  and  parts 
of  the  city  occupied  by  the  poor  than  in  cleaner  and  less  crowded 
streets  and  apartments. 

Summer  heat  and  the  anti-hygienic  conditions  to  which  it  gives 
rise  in  the  cities,  sometimes  appear  to  be  sufficient  in  themselves 
to  develop  cholera  infantum ;  at  least  it  occurs  without  other 
obvious  cause.  In  other,  and  probably  the  majority  of  cases, 
another  cause  co-operates,  namely,  the  use  of  improper  food. 
Atmospheric  heat  and  its  depressing  influences  are  then  predis- 
posing causes,  while  the  use  of  indigestible  or  irritating  food  is  the 
exciting  cause.  Infants  upon  whom  both  causes  are  operative  are 
most  liable  to  cholera  infantum  in  its  severe  form.  Hence  bottle- 
fed  infants  of  the  city  are  especially  liable  to  it,  and  infants  whose 
food  is  carelessly  and  improperly  prepared.  Often  in  the  hot 
months,  acid  and  indigestible  fruits,  as  currants,  heedlessly  given 
to  an  infant,  occasion  the  attack. 

Cholera  infantum  occurs  commonly  under  the  age  of  two  years. 
It  is  so  frequent  during  the  period  of  first  dentition,  that  some 
writers  consider  dentition  a  cause.  At  this  period,  however,  as 
has  been  stated  elsewhere,  there  is  great  functional  activity,  and 
rapid  development  of  the  intestinal  follicles,  and  the  peculiar 
liability  to  cholera  infantum  at  this  age  should  be  attributed  to 
this  cause  rather  than  to  dentition. 

Symptoms. — Cholera  infantum  sometimes  commences  abruptly^ 
the  previous  health  having  been  good.  In  other  cases  it  is  pre- 
ceded by  a  premonitory  stage,  that  of  simple  diarrhoea.  The  stools 
are  thinner  than  natural,  and  somewhat  more  frequent,  but  not 
such  as  to  excite  alarm.  Suddenly  the  evacuations  become  more 
40 


626  CHOLERA    INFANTUM. 

frequent  and  watery,  and  the  parents  are  surprised  and  frightened 
by  the  rapid  sinking  and  real  danger  of  the  infant.  Occasionally 
this  antecedent  diarrhoea  has  continued  several  weeks,  attended 
with  emaciation,  and  associated,  perhaps,  with  intestinal  inflam- 
mation. 

This  disease  is  characterized  by  the  discharge  of  thin  stools, 
designated  by  some  watery,  by  others  serous.  The  first  evacuations, 
unless  there  has  been  previous  diarrhcea,  contain  considerable  faecal 
matter.  They  are  so  thin  as  to  soak  into  the  diaper  almost  like 
urine,  and  in  some  cases  they  scarcely  produce  more  of  a  stain  than 
does  this  secretion.  The  odor  is  peculiar,  not  fsecal,  but  musty 
and  oftensive;  occasionally  the  stools  are  almost  odorless.  Com- 
mencing simultaneously  with  the  watery  evacuations,  or  soon  after, 
is  another  symptom,  namely,  irritability  of  the  stomach,  which 
increases  greatly  the  prostration  and  danger.  "Whatever  is  swal- 
lowed by  the  infant  is  rejected  immediately,  or  after  a  few  minutes, 
or  there  may  be  retching  without  vomiting.  The  appetite  is  lost, 
and  the  thirst  is  intense.  Cold  water,  especially,  is  taken  with 
avidity,  and  if  the  infant  nurses,  it  eagerly  seizes  the  breast,  in 
order  to  relieve  the  thirst.  The  tongue  is  moist  at  first,  and  clean 
or  covered  with  a  light  fur.  The  pulse  is  accelerated,  while  the 
respiration  is  either  natural  or  somewhat  increased  in  frequency ; 
the  surface  is  warm,  but  its  temperature  is  speedily  reduced. 
There  is  no  abdominal  tenderness,  and  no  evidence  of  pain.  The 
infant  is  often  restless  at  first,  but  its  restlessness  is  due  to  thirst, 
or  that  unpleasant  sensation  which  the  sick  exj^erience  when  the 
vital  powers  are  rapidly  reduced.  The  urine  is  scanty  in  propor- 
tion to  the  gravity  of  the  attack. 

The  loss  of  strength  and  the  emaciation  are  more  rapid  than  in 
any  other  diarrhceal  malady,  except  Asiatic  cholera,  and  the  most 
severe  form  of  cholera  morbus.  The  parents  scarcely  recognize  in 
the  changed  and  melancholy  aspect  of  the  infant  any  resemblance 
to  the  features  which  it  exhibited  a  day  or  two  before.  The  eyes 
are  sunken,  the  eyelids  and  lips  are  permanently  open  from  the 
feeble  contractile  power  of  the  muscles  which  close  them,  while  the 
loss  of  the  fluids  from  the  tissues  and  the  emaciation  are  such  that 
bony  angles  become  more  prominent,  and  the  skin  in  places  lies  in 
folds. 

As  the  disease  approaches  a  fatal  termination,  which  often  occurs 
in  two  or  three  days,  the  infant  remains  quiet,  not  disturbed  even 
by  the  flies  which  alight  upon  its  face.  The  limbs  and  cheeks 
become  cool ;  the  eyes  bleared,  and  pupils  contracted.     A  state  of 


ANATOMICAL    CHARACTERS.  627 

stupor  results,  from  which  there  is  no  relief,  and  which  after  a  few 
hours  ends  in  death. 

Often,  even  in  cases  which  are  ultimately  fatal,  there  is  not  such 
a  speedy  termination  of  the  disease.  The  choleriform  diarrhoea 
ends  in  inflammation,  which  runs  a  protracted  and  ohstinate  course. 
The  disease  then  becomes  the  entero-colitis,  inflammatory  diarrhcea, 
or  intestinal  inflammation  of  writers. 

In  the  most  favorable  cases  of  cholera  infantum  the  patient  re- 
covers before  the  supervention  of  inflammation. 

Anatomical  Characters. — Rilliet  and  Barthez,  who  of  foreign 
writers  treat  of  this  disease  at  greatest  length,  describe  it  under 
the  name  of  gastro-intestinal  choleriform  catarrh.  "The  perusal," 
they  remark,  "of  the  anatomico-pathological  description,  and  es- 
pecially the  study  of  the  facts,  show  that  the  gastro-intestinal  tube 
in  subjects  who  succumb  to  this  disease  may  be  in  four  diflferent 
states:  (a),  either  the  stomach  is  softened  without  any  lesion  of 
the  digestive  tube ;  (6),  or  the  stomach  is  softened  at  the  same  time 
that  the  mucous  membrane  of  the  intestine,  and  especially  its  fol- 
licular apparatus  is  diseased  ;  (c),  or  the  stomach  is  healthy  whilst 
the  follicular  apparatus,  or  the  mucous  membrane,  is  diseased  ;  (d), 
or,  finally,  the  gastro-intestinal  tube  is  not  the  seat  of  any  lesion 
appreciable  to  our  senses  in  the  present  state  of  our  knowledge,  or 
it  presents  lesions  so  insignificant  that  they  are  not  suflScient  to 
explain  the  gravity  of  the  symptoms. 

"So  far  the  disease  resembles  all  the  catarrhs,  but  what  is  special 
is  the  abundance  of  the  serous  secretion,  and  the  disturbance  of 
the  great  sympathetic  nerve. 

"The  serous  secretion,  which  appears  to  be  produced  by  a  per- 
spiration (analogous  to  that  of  the  respiratory  passages  and  of  the 
skin)  rather  than  by  a  follicular  secretion,  shows,  perhaps,  that 
the  elimination  of  substances  is  efi'ected  by  other  organs  than  the 
follicles ;  perhaps,  also,  we  ought  to  see  a  proof  that  the  materials 
to  eliminate  are  not  the  same  as  in  simple  catarrh.  Upon  all  these 
points  we  are  constrained  to  remain  in  doubt.  We  content  our- 
selves with  pointing  out  the  fact." 

American  writers  very  generally  divide  cholera  infantum  into 
three  stages,  the  first  characterized  by  turgescence  of  the  intestinal 
follicles  without  inflammation,  but  perhaps  attended  by  more  or 
less  softening  of  the  mucous  membrane.  In  the  second  stage  intes- 
tinal inflammation  is  present.  The  mucous  membrane  of  the  in- 
testines is  vascular  in  patches  and  streaks,  sometimes  thickened, 
and  the  solitary  glands  and  patches  of  Peyer  are  inflamed,  and  oc- 


628  CHOLERA    INFANTUM. 

casionally  certain  of  them  are  ulcerated.  In  tlie  third  stage  the 
brain  is  involved.  The  cranial  sinuses,  veins,  and  capillaries  of 
the  brain  are  congested,  and  there  is  transudation  of  serum  upon 
the  surface  of  the  brain  or  in  the  ventricles.  But  the  second  and 
third  stages  of  these  writers  pertain,  in  my  opinion,  as  I  have 
already  said,  to  entero-colitis,  a  supervening  disease,  and  distinct 
from  cholera  infantum.  The  anatomical  character  of  the  first 
stage  alone  is  that  of  cholera  infantum,  as  the  disease  is  understood 
by  us.  In  our  restricted  use  of  the  term,  the  appreciable  lesions 
in  cholera  infantum  are  seen  to  be  similar  to  those  in  the  common 
forms  of  non-inflammatory  diarrhoea.  The  following  observations 
show  the  character  of  these  lesions : — 

On  the  first  of  August,  1861, 1  made  an  autopsy  of  an  infant 
sixteen  months  old,  who  died  of  cholera  infantum,  with  a  sickness 
of  less  than  one  day.  The  examination  was  made  thirty  hours 
after  death.  Il^othing  unusual  was  observed  in  the  brain,  except, 
perhaps,  a  little  more  than  the  ordinary  injection  of  vessels  at  the 
vertex;  no  disease  of  stomach  and  intestines  except  enlargement 
of  the  patches  of  Peyer  as  well  as  the  solitary  glands ;  mucous 
membrane  pale.  In  this  and  the  following  cases  there  was  appa- 
rently slight  softening  of  the  intestinal  mucous  membrane ;  but 
whether  it  was  pathological  or  cadaveric  is  uncertain,  as  the 
weather  was  very  w^arm.  The  liver  seemed  healthy.  Examined 
by  the  microscope,  it  was  found  to  contain  about  the  normal  amount 
of  oil-globules. 

The  second  case  was  that  of  an  infant  seven  months  old,  wet- 
nursed,  who  died  July  26th,  1862,  after  a  sickness  also  of  about 
one  day.  He  was  previously  emaciated,  but  without  any  definite 
ailment.  The  post-mortem  examination  was  made  on  the  28th. 
The  brain  was  somewhat  softer  than  natural,  but  was  otherwise 
healthy.  There  was  no  abnormal  vascularity  of  the  membranes 
of  the  brain,  and  no  serous  eftusion  within  the  cranium.  The 
mucous  membrane  of  the  intestines  was  of  healthy  appearance 
throughout,  except  that  the  solitary  glands  of  the  colon  were 
enlarged.     The  patches  of  Peyer  were  not  distinct. 

At  the  New  York  Prostestant  Episcopal  Orphan  Asylum,  an 
infant  twenty  months  old,  previously  healthy,  was  seized  with 
cholera  infantum  on  the  25th  of  June,  1864.  The  dejections,  as  is 
usual  in  that  disease,  were  frequent  and  watery,  and  attended  by 
obstinate  vomiting.  Death  occurred  in  slight  spasms,  in  thirty- 
six  hours.  The  exciting  cause  was  apparently  the  use  of  a  few 
currants,  which  were  eaten  in  a  cake  the  day  before,  some  of  which 


ANATOMICAL    CnARACTERS,  629 

fruit  was  contained  in  the  first  evacuations.  The  hrain  was  not 
examined.  The  only  pathological  changes  which  were  observed 
in  the  stomach  and  intestines  were  slight  vascular  patches  in  the 
small  intestines,  scarcely  sufficient  to  be  considered  inflammatory 
or  even  congestive,  and  an  unusual  prominence  of  the  solitary 
glands  in  the  colon.  These  glands  resembled  small  beads  imbed- 
ded in  the  mucous  membrane.  The  lungs  in  the  above  cases  were 
health}^,  excepting  hypostatic  congestion. 

The  lesions  in  the  above  cases  obviously  lacked  those  characters 
which  indicate  an  inflammatory  disease.  The  observations  of 
others  correspond  with  our  own  in  reference  to  these  severe  and 
suddenly  fatal  cases. 

Dr.  Hallowell,  in  a  paper  on  this  disease  published  in  the  Ame?-i- 
can  Journal  of  the  Medical  Sciences^  J^^ly?  1847,  says  of  the  anatomical 
characters  of  the  first  stage:  "  These  consist  in  an  undue  develop- 
ment of  the  follicles,  both  of  the  stomach  and  intestines,  or  of  one 
of  those  organs,  without  inflammation  of  the  mucous  membrane." 

Dr.  E.  H.  Parker,  in  a  paper  read  before  the  IsTew  York  State 
Medical  Society,  February  4th,  1857,  says :  "  When  death  occurs 
from  the  exhaustion  produced  by  the  profuse  vomiting  and  diar- 
rhoea, a  condition  to  which  is  given  in  this  country  the  name  of 
cholera  infantum,  we  find  the  intestines  to  contain  more  or  less  of 
a  soft,  usually  light  yellow  foecal  matter,  and  the  stomach  a  fluid 
resembling  a  thin  gruel.  The  walls  of  the  stomach  are  natural, 
unless  the  epithelial  lining  be  a  little  too  easily  removed,  the  epi- 
thelial lining  of  the  small  intestines  and  sometimes  of  the  large 
being  in  a  similar  state.  The  walls  of  the  intestines  are  almost 
translucent,  bloodless  and  apparently  thin.  Throughout  their  whole 
extent  the  solitary  and  agglomerated  glands  are  very  prominent, 
setting  up  almost  like  beads  upon  the  surface." 

Both  these  writers,  as  well  as  Stewart  in  his  monograph  on 
cholera  infantum,  admit  the  frequent  termination  of  the  patho- 
logical state  just  described,  in  other  words,  of  cholera  infantum, 
according  to  our  restricted  use  of  the  term,  in  entero-colitis.  Most 
writers,  as  we  have  elsewhere  stated,  regard  the  entero-colitis  as 
an  advanced  stage  of  cholera  infantum.  I  believe  that  the  opinion 
of  writers  is  correct,  that  there  is  usually  in  chlorea  infantum  soft- 
ening of  the  gastro-intestinal  mucous  membrane,  at  least  in  places. 
But  as  the  autopsies  in  this  disease  are  made  in  the  warmest 
weather,  and  after  the  lapse  of  several  hours,  it  is  difficult  to  de- 
cide how  much  of  this  change  pertains  to  this  disease  and  how 
much  is  post-mortem. 


630  CHOLERA    INFANTUM. 

"With  the  exception  of  the  organs  of  digestion,  no  uniform  lesion 
is  observed  in  any  of  the  viscera,  unless  such  as  is  due  to  change 
in  the  quantity  and  fluidity  of  the  blood,  and  in  its  circulation. 
Writers  describe  an  anaemic  appearance  of  the  thoracic  and  abdomi- 
nal viscera,  and  occasional  passive  congestion  of  the  cerebral  ves- 
sels. The  cerebral  symptoms  often  present  towards  the  close  of 
life  in  unfavorable  cases  of  cholera  infantum  may  arise  from  a 
state  of  the  brain  similar  to,  if  not  identical  with,  spurious  hydro- 
cephalus, which  state  is  not  attended  by  any  uniform  or  certain 
lesion  of  this  organ.  As  the  urinary  secretion  is  scanty  or  sup- 
pressed, cerebral  symptoms  may  in  certain  cases  be  due  to  uraemia. 
Diagnosis. — This  disease  is  diagnosticated  by  the  symptoms, 
and  especially  by  the  frequency  and  character  of  the  stools.  The 
stools  have  already  been  described  as  frequent,  often  passed  with 
considerable  force,  deficient  in  faecal  matter,  and  thin,  so  as  to  soak 
into  the  diaper  almost  like  urine.  The  vomiting,  thirst,  rapid 
sinking,  and  emaciation  serve  to  distinguish  cholera  infantum 
from  other  diarrhoeal  affections. 

When  Asiatic  cholera  is  prevalent,  the  differential  diagnosis  of 
the  two  diseases  is  difficult  if  not  impossible. 

Prognosis. — This  is  one  of  those  diseases  in  regard  to  which 
physicians  often  injure  their  reputation  by  not  giving  sufficient 
notice  of  the  danger,  or  even  by  expressing  a  favorable  opinion,  when 
the  case  soon  after  ends  fatally.  A  favorable  prognosis  should 
seldom  be  expressed  without  qualification.  If  the  urgent  symp- 
toms are  relieved,  still  there  is  danger  of  the  occurrence  of  intes- 
tinal inflammation,  which,  in  hot  weather,  is  formidable  and  often 
fatal.  If  the  stools  become  more  consistent  and  less  frequent, 
without  the  occurrence  of  cerebral  symptoms,  we  may  confidently 
express  the  opinion  that  there  is  no  present  danger. 

The  duration  of  true  cholera  infantum  is  short.  It  either  ends 
fatally,  or  it  begins  soon  to  abate  and  ceases,  or  it  is  transformed 
into  an  inflammation.  Death  may  occur,  in  twenty-four  or  forty- 
eight  hours,  in  a  state  of  collapse,  from  the  frequency  of  the  stools, 
or  not  till  after  three  or  four  days.  In  general,  if  the  patient  is 
not  relieved  in  three  or  four  days,  entero-colitis  commences. 

Treatment. — The  frequency  and  watery  character  of  the  stools 
in  cholera  infantum,  and  the  consequent  rapid  sinking  of  the 
infant,  call  for  prompt  measures  for  the  arrest  of  the  disease.  If 
there  is  any  irritating  substance  in  the  stomach  or  intestines, 
which  acts  as  an  exciting  cause  of  the  vomiting  or  diarrhoea,  or  at 
least  aggravates  it,  it  is  proper  to  commence  treatment  by  the  use 


TREATMENT.  631 

of  some  cvacuant.  Dr.  James  Jackson  [Letters  to  a  Young  Physi- 
cian) says:  "In  the  acute  attacks  of  cholera  infantum,  the  first 
object  is  the  dislodgement  of  offending  materials  from  the  alimen- 
tary canal.  In  most  cases  the  spontaneous  efforts  suffice  to  clear 
the  stomach.  But,  occasionally,  it  is  evident  that  these  efforts  fail 
to  remove  a  load  which  the  patient  has  imprudently  been  per- 
mitted to  take  into  the  stomach.  Then  small  doses  of  ipecacuanha 
may  be  given  with  benefit  till  the  burden  is  thrown  off.  Two  to 
four  grains  will  usually  suffice.  Much  more  frequently  the  efforts 
of  the  bowels  are  not  successful  in  carrying  off"  their  contents,  and 
the  stomach  is  at  the  same  time  so  irritable  as  not  easily  to  retain 
medicine.  Then  calomel  is  the  great  remedy.  Whatever  objec- 
tions theoretical  men  may  make  to  the  use  of  so  potent  a  drug 
for  a  tender  infant,  few  practical  men,  after  having  tried  it, 
are  willing;  to  treat  this  disease  without  this  article.  It  is  not 
offensive  to  the  taste ;  it  can  be  retained  when  scarce  any  other 
medicine  can  be ;  and,  if  vomiting  follows  a  dose  of  it,  the  stomach 
becomes  less  irritable,  so  that  a  way  is  open  for  other  medicines  or 
for  nourishment.  By  its  operation  the  bowels  are  disburdened  of 
their  load  with  benefit.  But  it  is  a  medicine  which  is  slow  in  its 
operation,  and  castor  oil  may  be  used  after  it  with  advantage." 

Unless  the  stomach  is  quite  irritable,  castor  oil,  syrup  of  rhubarb, 
or,  if  there  is  a  state  of  acidity,  rhubarb  and  magnesia,  are  generally 
sufficient  to  remove  the  indigestible  substance.  Dr.  E.  H.  Parker 
prefers  the  syrup  of  rhubarb  in  such  cases.  If  the  stomach  is  irri- 
table, so  that  the  purgatives  mentioned  would  be  vomited,  calomel 
is  certainly  the  best  medicine.  This  should  not  be  given  to  the 
extent  of  more  than  one  or  two  doses,  and  it  may  be  aided  by  a 
simple  enema. 

If  there  is  no  indigestible  substance  in  the  intestines,  purgatives 
should  not  be  used,  as  they  would  then  do  more  harm  than  good. 
If  the  disease  has  continued  several  hours,  it  is  probable  that  any 
irritating  substance,  which  might  have  been  present  at  first,  has 
passed  from  the  bowels,  and  no  purgative  is  required. 

Treatment  designed  to  diminish  the  frequency  of  the  evacuations 
'and  improve  their  character,  should  be  commenced  at  the  earliest 
moment. 

Every  hour  that  cholera  infantum  continues  unchecked  reduces 
the  strength  of  the  infant  and  diminishes  his  chance  of  recovery. 
Our  main  reliance  must  be  on  opium  in  some  form.  Dr.  Jackson 
truly  remarks  that  we  have  no  substitute  for  it.  "From  three  to 
five  drops  of  the  tincture  of  opium,"  says  he,  "  may  be  given,  and 


632  CHOLERA    INFANTUM. 

the  dose  may  be  repeated  in  eight  or  twelve  hours."     This  he 
recommends  "after  the  bowels  are  unburdened." 

It  is  better  to  give  a  smaller  dose  of  opium  and  repeat  it  often. 
If  laudanum  is  used,  it  may  be  given  in  one  drop  doses  eYery  two 
or  three  hours  to  a  child  one  year  old,  its  effect  being  watched. 
There  is  danger  in  this  disease  of  the  sudden  supervention  of 
stupor,  amounting  even  to  coma  and  ending  fatally.  In  these 
cases  the  stools  are  g-enerally  suddenly  checked,  and  the  opiate 
might  aid  in  producing  this  result.  In  a  few  instances  which  I 
can  recall  to  mind,  where  death  occurred  in  this  way,  the  friends 
believed  that  the  melancholy  result  was  hastened  by  the  medicine. 
If  the  evacuations  are  partially  checked  and  there  are  signs  of 
stupor,  the  oj^iate  should  either  be  omitted  or  given  less  frequently. 
Explicit  and  positive  directions  to  this  effect  should  be  given. 
Eligible  preparations  of  opium  for  this  disease  are  paregoric, 
tincture  of  opium,  pulv.  cretse  comp.  c.  opio,  and,  if  there  is  no  irri- 
tability of  stomach,  Dover's  powder. 

Astringents  and  often  alkalies  are  useful  employed  as  adjuvants 
of  the  opiate.  The  chief  danger  is  from  the  frequent  watery 
evacuations,  and  both  these  remedies  certainly  aid  materially  in 
restraining  them.  Astringents  are  less  tolerated  by  an  irritable 
stomach  than  either  opium  or  chalk,  so  that  it  is  often  advisable 
to  discontinue  their  use  when  they  are  vomited,  in  cases  in  which 
they  would  be  very  beneficial  if  the  stomach  were  retentive.  The 
opiate  and  alkali  may  be  employed  in  the  following  combination: — 

]^.  Tinct.  opii  gtt.  xij ; 

Mistur.  cretse  §iss.     Misce. 
One  teaspoonful  eyery  two  or  three  hours  to  an  infant  one  year  old.     To  this 
mixture  an  astringent  may  be  added,  as  tincture  of  catechn  or  kino. 

f  I  prefer  for  ordinary  cases,  as  it  is  astringent,  alkaline,  opiate, 
and  anti-emetic,  the  powder  of  subnitrate  of  bismuth  and  chalk 
with  opium,  already  recommended  for  intestinal  inflammation. 

By  this  mode  of  treatment  the  stools  are  generally  in  a  few  hours 
rendered  less  frequent  and  more  consistent. 

There  are  physicians  who  believe  that  calomel  given  in  small 
and  repeated  doses  has  a  beneficial  eft'ect  in  choleriform  diarrhoea, 
but  those  who  use  it  employ  it  in  combination  with  opium,  and  it 
is  probable  that  the  good  effect  observed  is  largely  due  to  the  latter 
remedy.  From  the  anatomical  characters  of  cholera-infantum 
there  is  apparently  no  indication  for  a  medicine  that  affects  the 
function  of  the  liver,  and  there  is  no  evidence  that  calomel  exerts 
any  good  effect  on  the  follicular  apparatus  of  the  intestines,  which, 


INTESTINAL    WORMS.  633 

80  far  as  wc  can  localize  the  disease,  seems  to  be  most  in  fault  of 
any  part  of  the  digestive  apparatus.  On  theoretical  grounds,  ^'\^ 
therefore,  I  should  oppose  the  employment  of  this  agent,  and  my 
observations  of  its  effects  have  been  such  that  I  entirely  discard  its 
use  while  we  have  other  safe  and  efficient  remedies  to  meet  every 
indication. 

Ordinarily,  as  the  diarrhoea  is  relieved,  the  vomiting  ceases. 
The  opiate  and  alkaline  remedies  employed  for  the  former  are  also 
curative  of  the  latter ;  still  the  vomiting,  if  frequent  and  obstinate, 
sometimes  does  require  special  treatment,  and  there  are  no  better 
anti-emetic  mixtures  than  those  recommended  in  our  remarks  on 
the  treatment  of  intestinal  inflammation.  In  robust  infants  at 
the  commencement  of  the  attack,  small  pieces  of  ice  taken  in  the 
mouth  aid  in  diminishing  the  irritability  of  stomach.  Mustard 
should  also  be  applied  to  the  epigastrium. 

In  most  cases  alcoholic  stimulants  are  required.  The  best  of 
these  is  Bourbon  whiskey  or  brandy,  which  should  be  used  from  an 
early  period  of  the  disease.  Aside  from  its  sustaining  the  vital 
powers,  it  aids  also  in  relieving  the  irritability  of  stomach. 

The  diet  in  cholera  infantum  should  be  simple  but  nutritious. 
It  should  be  given  little  at  a  time  and  often.  If  the  infant  nurse, 
it  should  be  confined  to  the  breast.  If  weaned,  cold  barley  or 
rice-water  should  be  given,  with  whiskey  or  brandy,  in  the  first 
stages  of  the  disease,  and  afterwards  milk  or  broths  may  be  em- 
ployed in  addition. 

If  cholera  infantum  end  in  inflammation,  the  treatment  already 
described  for  that  disease  should  be  adopted. 


CHAPTER   XI. 

INTESTINAL  WORMS. 

The  belief  has  been  prevalent  in  the  profession,  and  is  now  in 
the  community,' that  the  presence  of  worms  in  the  intestines  con- 
stitutes a  frequent  disease  in  early  life.  As  the  pathology  of  in- 
fancy and  childhood,  and  especially  the  means  of  diagnosticating 
diseases,  are  better  understood,  this  idea  is  gradually  abandoned 
by  the  profession.  Still,  intestinal  worms  must  be  considered  an 
occasional  cause  of  serious  derangement  or  even  disease,  and  of 
death  also. 


634  INTESTINAL    WORMS. 

Worms,  indeed,  may  exist  in  the  intestines  without  any  appre- 
ciable deviation  in  the  individual  from  a  state  of  health.  Ordi- 
narily, however,  they  in  time  give  rise  to  symptoms  so  as  to  require 
the  use  of  remedies  for  their  expulsion. 

There  are  five  kinds  of  worms  whose  habitat  is  the  human 
intestines,  namely,  the  ascaris  lumbricoides,  ascaris  vermicularis, 
or,  as  it  is  sometimes  called,  the  oxyuris  vermicularis,  the  tricho- 
cephalus  dispar,  and  two  species  of  taenia.  The  ascaris  lumbri- 
coides, when  matured,  measures  from  five  inches  to  about  a  foot 
in  length.  Young  ones  are  sometimes  expelled  not  more  than 
two  inches  in  length.  The  color  is  a  reddish-brown,  with  a  shade 
of  yellow.  The  dead  worm  has  a  paler  color.  The  females  are  in 
numerical  excess  of  the  males,  and  their  size  is  also  greater.  The 
worm  in  shape  resembles  the  common  earthworm,  from  which  it 
derives  the  name  lumbricus.  It  is,  however,  more  pointed  at 
both  extremities  than  the  earthworm,  and  the  color  is  a  paler  red. 
The  tail  of  the  male  worm  is  curved,  while  that  of  the  female  is 
straight.  The  mouth  is  triangular,  and  is  surrounded  by  three 
tubercles. 

The  ascaris  lumbricoides  resides  usually  in  the  small  intestines. 
It  occasionally  enters  the  stomach,  from  which  it  is  vomited,  or 
it  crawls  up  the  oesophagus  into  the  fauces,  from  which  it  is  soon 
removed  by  the  efforts  of  the  individual.  Cases  are  on  record, 
one  of  which  Andral  witnessed,  in  which  the  worm  entered  the 
larynx,  producing  suftbcation  and  speedy  death.  M.  Tonnelle 
also  witnessed  such  a  case.  A  child  nine  years  old  was  suddenly 
seized  with  great  difficulty  of  respiration  and  pain  in  the  uj)per 
part  of  the  chest.  A  careful  examination  of  the  thorax  gave  a 
negative  result.  Death  occurred  in  from  twelve  to  fifteen  hours, 
and  at  the  post-mortem  examination  a  lumbricus  was  found  filling 
the  cavity  of  the  larynx.  M.  Blandin,  also,  witnessed  a  case, 
when  interne  of  the  Hopital  des  Enfants.  An  infant  was  suffo- 
cated by  one  of  these  worms,  which  had  penetrated  as  far  as  the 
right  bronchus.  Very  rarely  they  crawl  from  the  fauces  into  the 
nasal  passages.  This  worm  is  so  strong  and  active,  that  there  is 
no  recess  or  reflexion  of  the  mucous  membrane  of  the  digestive 
apparatus  which  it  could  possibly  penetrate,  in  which  it  has  not 
been  found.  It  has  been  discovered  in  the  appendix  vermiformis, 
in  the  pancreatic  duct,  in  the  common  bile-duct,  and  even  in  the 
gall-bladder.  The  number  of  these  worms  found  in  the  intestines 
is  very  various.  There  may  be  only  one,  or  the  number  may  be 
almost  incredibly  large. 


ASOARIS    LUMBRIC0IDE3,  635 

Thus,  Barrier  relates  the  case  of  an  infant  thirty  months  old, 
who  died  in  Hospital  Nccker.  It  was  believed  to  be  tubercular. 
Numerous  tumors,  which  could  be  felt  in  the  abdomen,  were  sup- 
posed to  be  tubercular  masses.  On  making  the  post-mortem  ex- 
amination, the  mesenteric  glands  were  found  healthy,  but  the  in- 
testines throughout  their  entire  extent  were  filled  with  lumbrici. 
The  masses  which,  during  life,  were  believed  to  be  tubercular 
glands,  were  found  to  consist  of  worms.  The  coecum,  especially, 
was  greatly  distended  by  them.  The  intertwining  or  collection  in 
balls  of  these  worms  constitutes,  indeed,  one  of  the  chief  dangers, 
as  it  renders  them  so  much  the  more  difficult  of  expulsion. 

The  round  worm,  as  this  worm  is  commonly  called,  possesses  no 
organs  of  penetration,  still,  if  the  intestine  is  weakened  by  disease, 
especially  by  ulceration,  it  may,  by  pressure  with  its  head,  force  an 
opening  through  which  it  escapes  into  the  cavity  of  the  abdomen, 
causing  peritonitis  and  death.  This  worm  is  often  found,  whether 
single  or  in  masses,  surrounded  with  mucus,  which  serves  as  a 
partial  protection  to  the  intestines. 

The  portion  of  the  mucous  membrane  in  contact  with  lumbrici 
is  often  found  inflamed,  either  from  movements  of  the  worm,  or 
from  pressure  of  a  mass  of  worms,  or  even  of  a  single  worm  in  a 
confined  position,  as  the  appendix  vermiformis.  This  inflamma- 
tion, continuing  and  increasing,  may  end  in  ulceration,  and  thus 
a  weakened  spot  be  produced,  which  may  be  ruptured  by  simple 
pressure  of  the  mouth  of  the  worm.  In  this  way  are,  probably, 
to  be  explained  those  apparent  cases  of  perforation,  which  have  led 
some  observers  to  believe  that  lumbrici  had  actually  the  power  of 
penetrating  the  healthy  coats  of  the  intestines. 

M.  Guersant  describes  a  case  in  which  the  appendix  vermiformis 
was  found  with  an  opening  through  which  two  lumbrici  had  partly 
passed  into  the  abdominal  cavity.  The  effect  of  their  impaction 
in  this  narrow  cul-de-sac  was  much  like  that  of  a  bean  or  a  seed 
lodged  in  the  same  situation. 

Lumbrici  are  sometimes  found  in  a  most  remarkable  location, 
namely,  in  little  abscesses,  external  to  the  intestines,  situated 
generally  in  the  abdominal  walls.  These,  after  a  time,  in  cer- 
tain cases,  open  externally,  discharging  pus,  one  or  more  worms, 
and  perhaps  a  little  excrementitious  matter.  They  result  from  an 
opening  in  the  intestine,  through  which  the  worm  has  passed,  pro- 
ducing circumscribed  inflammation  and  an  abscess,  and  the  intes- 
tine, now  relieved  of  the  irritant,  heals  before  the  abscess  reaches 
the  surface. 


636  INTESTINAL    WORMS. 

The  mucous  membrane  in  contact  with  the  worm  sometimes 
presents  the  natural  appearance;  in  other  cases,  it  is  red,  being 
evidently  inflamed.  ^ 

The  ascaris  vermicularis,  or  oxyuris  vermicularis,  or,  as  it  is 
termed  in  the  vernacular,  the  threadworm,  is  also  frequent  in 
childhood,  and  is  the  cause  sometimes  of  much  suifering,  though 
generally  of  less  dangerous  symptoms  than  the  round  worm.  Its 
habitat  is  the  large  intestine,  commonly  the  rectum.  Bremser 
states  that  he  found  it  even  in  the  caecum.  This  worm  resembles 
pieces  of  white  thread,  and  hence  its  common  name.  The  female 
is  larger  than  the  male,  measuring  about  half  an  inch  in  length, 
while  the  length  of  the  male  is  not  more  than  two  or  three  lines, 
and  it  is  pro]3ortionately  more  slender.  It  exists  often  in  vast 
numbers  in  the  rectum,  from  which  it  is  expelled  with  the  excre- 
mentitious  matter.  The  head  of  the  worm  is  blunt,  and  is  furnished 
with  a  transparent  vesicle.  The  tail  is  very  slender,  terminating 
in  a  spiral  in  the  male,  while  it  is  straight  in  the  female.  These 
worms  multiply  rapidly,  and  they  move  actively  their  anterior 
extremity.  In  girls  they  sometimes  enter  the  vagina,  producing  a 
leucorrhoeal  discharge. 

The  trichocephalus  dispar,  or  the  long  threadworm,  is  also  found 
in  the  large  intestine,  but  oftener  in  the  caput  coli  or  ascending 
colon  than  elsewhere.  It  measures  in  length  one  and  a  half  inches, 
sometimes  even  two  inches.  The  anterior  two-thirds  are  slender, 
resembling  in  size  and  appearance  a  hair,  whence  its  name  tricho- 
cephalus. The  posterior  third  is  considerably  larger  than  the 
anterior,  being,  like  the  ascaris  vermicularis,  spiral  in  the  male  and 
straighter  in  the  female.  The  worm  is  of  a  light  color.  Children 
are  less  frequently  affected  with  the  trichocephalus  than  with  the 
two  kinds  just  described.  It  rarely,  if  ever,  produces  any  symptoms 
or  does  any  appreciable  injury. 

The  tfenia,  or  tapeworm,  is  much  less  frequent  than  the  round 
or  threadworm.  There  are  two  recognized  species,  the  taenia 
solium  and  taenia  lata.  These  worms  have  minute  heads,  which 
are  different  in  the  two  species.  Their  bodies  consist  of  white 
flat  segments,  which  are  united  in  a  diflferent  manner  in  the  two 
species.  These  segments  near  the  head  are  small,  as  if  rudimental, 
but  as  the  distance  from  the  head  increases  they  enlarge,  till  their 
full  development  is  attained.  They  are  quadrilateral,  having, 
when  fully  developed,  greater  length  than  breadth  in  the  taenia 
solium,  greater  breadth  than  length  in  the  taenia  lata. 

The  taenia  is  an  hermaphrodite,  each  segment  containing  the 


CAUSES.  637 

reproductive  organs  complete.  The  oviduct  opens  in  the  centre  of 
the  flat  surface  in  the  taenia  solium,  upon  the  edge  of  the  segment 
in  the  taenia  lata. 

The  taenia  attains  a  great  length,  but  its  maximum  of  growth  is 
not  ascertained,  as  pieces  are  generally  detached  and  expelled  from 
time  to  time  before  the  removal  of  the  entire  worm.  The  taenia 
lata  is  supposed  to  attain  the  length  of  about  fifteen  feet.  The 
taenia  solium  is  considerably  longer. 

The  taenia  is  rare  in  early  life,  but  cases  now  and  then  occur.  I 
have  met  but  one  case  in  this  city  under  the  age  of  five  years. 
Rosen  and  Bremser  report  cases  between  the  ages  of  six  and  eleven 
years,  and  Ilufeland,  one  at  the  age  of  six  months.  "Wawruch 
collected  206  observations  of  taenia,  in  22  of  which  the  age  was 
less  than  fifteen  years ;  the  youngest  was  a  girl  of  three  years.  A 
most  remarkable  case  of  taenia  is  reported  in  the  Gazette  Medicale 
of  Paris  in  1837.  M.  MuUer  was  called  to  treat  a  foster  child  five 
days  old  for  slight  constipation.  The  bowels  were  evacuated  by 
the  use  of  rhubarb,  manna,  and  a  few  grains  of  salt,  and  in  the 
excrement  a  foot  and  a  half  of  taenia  were  discovered.  This  worm 
had  evidently  existed  during  the  foetal  life  of  the  infant. 

A  similar  case  was  treated  by  Prof.  Skene,  in  the  Long  Island 
Hospital,  in  September,  1871,  and  reported  by  Dr.  Armor  in  the 
New  York  Medical  Journal.  The  infant  was  born,  September  3d,  of 
a  hearty  Irish  servant  girl.  On  the  7th  it  refused  to  nurse,  and 
was  observed  to  have  a  mild  form  of  tetanus.  On  the  8th  small 
doses  of  calomel  having  been  given,  followed  by  castor  oil,  two 
segments  of  a  taenia  solium  were  passed  from  the  bowels,  and  on 
subsequent  days  ten  more  segments,  after  which  the  tetanus  ceased. 
The  remedies  employed  after  September  8th  were  the  oil  of  male  fern 
and  turpentine.  The  mother,  who  had  presented  no  symptoms  of 
taenia,  was  ordered  an  emulsion  of  pumpkin-seeds,  which  "  she  faith- 
fully took  for  twenty-four  hours,  at  the  end  of  which  she  passed 
over  seventy  segments  of  taenia."  This  case  is  interesting  as 
throwing  light  on  a  possible  mode  of  the  production  of  taenia, 
quite  difterent  from  the  ordinary  and  recognized  mode,  and  also  as 
showing  the  causative  relation  of  intestinal  worms  to  tetanus 
infantum. 

Causes. — The  vermicular  disease  is  much  more  common  in  one 
locality  than  another.  Thus,  in  Paris  there  are  few  cases,  while 
in  the  provinces  of  France  and  many  other  parts  of  Europe  it  is  a 
common  affection.  It  is  more  common  in  this  city  among  the 
children  of  the  poor  than  those  in  the  better  walks  of  life. 


638  INTESTINAL    WORMS. 

In  the  same  region,  with  an  identity  of  regimen,  pursuits,  and 
habits,  it  is  sometimes  common  in  one  season,  and  rare  in  another. 
It  is  an  interesting  fact,  also,  as  showing  the  influence  of  local 
causes,  which  we  often  cannot  appreciate,  that,  in  countries  where 
the  disease  prevails,  the  relative  frequency  of  the  diiFerent  kinds 
of  worms  is  often  different.  Thus,  in  England,  Holland,  and  Ger- 
many, the  taenia  solium  is  common,  and  the  tsenia  lata  rare,  while 
the  reverse  is  true  of  Russia,  Poland,  and  Switzerland. 

There  is  often  some  derangement  or  disease  of  the  digestive 
system,  which  is  favorable  for  the  growth  of  intestinal  worms.  In 
cases  of  continued  indigestion,  accompanied  by  irritation  or  sub- 
acute inflammation  of  the  mucous  surface,  with  an  excessive  secre- 
tion of  mucus,  worms  are  apt  to  be  generated,  which  aggravate 
the  primary  affection.  Children  in  the  last  stages  of  typhoid  fever 
not  infrequently  pass  lumbrici  in  the  evacuations  from  the  bowels. 

It  has  long  been  a  common  and  correct  belief  that  the  use  of 
certain  kinds  of  food  favors  the  development  of  worms.  Fruits  in 
excess,  food  of  an  inferior  quality,  or  but  partially  cooked,  remain- 
ing an  unusual  time  unassimilated  in  the  intestines,  afford  a  nidus 
in  which  worms  are  very  apt  to  appear.  The  same  may  be  said 
of  saccharine  substances,  taken  in  too  large  quantity  or  too  fre- 
quently. An  excess  of  food,  even  of  good  quality,  is  also  a  cause, 
since  this  gives  rise  to  the  predisposing  condition  of  undigested 
nutriment  in  the  intestines.  The  period  of  childhood  is  mentioned 
by  writers  as  one  of  the  predisposing  causes.  Both  the  round  and 
threadworms  occur  oftenest  in  children  between  the  ages  of  three 
and  ten  years,  but  they  are  not  very  infrequent  at  any  age  between 
the  first  year  and  puberty. 

I  have  witnessed  a  large  number  of  autopsies  of  infants  in  the 
institutions  of  this  city,  and,  although  the  intestines  in  a  large 
proportion  of  them  were  examined,  I  can  recall  only  one  instance 
in  which  intestinal  worms  were  present  when  death  had  occurred 
in  the  first  year.  This  immunity  is,  however,  in  great  part  attri- 
butable to  the  simple  diet  of  these  institutions.  The  infrequency 
of  worms  in  the  first  year  of  life  is  an  important  practical  fact. 
The  immunity  is  greatest,  for  obvious  reasons,  in  those  who  are 
nourished  entirely  or  almost  entirely  at  the  breast. 

In  this  city,  children  of  the  poor,  living  in  almost  total  disregard 
of  sanitary  requirements,  are  especially  liable  to  worms.  This  is 
attributable  not  only  to  the  character  of  their  food,  which  is  often 
of  inferior  quality  and  poorly  prepared,  but  also  to  the  filthy  and 
insalubrious  state  of  the  domiciles  and  streets  in  which  they  reside. 


SYMPTOMS.  639 

and  the  consequent  cachexia.  One  of  the  older  writers  remarks  that 
intestinal  worms,  like  confervoid  growths,  thrive  best  where  it  is 
filthy  and  dark.  Though  such  analogical  reasoning  is  not  to  be 
accepted,  the  fact  remains  of  the  great  liability  to  worms  of  those 
children  who  reside  in  insalubrious  and  humid  localities  which  are 
favorable  also  for  cryptogamic  vegetation. 

Symptoms  op  Lumbrici. — These  are  in  part  constitutional  or 
sympathetic,  and  in  patt  local,  due  to  the  mechanical  effect  of 
these  entozoa  on  the  coats  of  the  intestines.  Writers,  especially 
Rillict  and  Barthez,  have  described  the  symptoms  supposed  to 
indicate  lumbrici  with  minuteness.  Those  of  a  constitutional  or 
sympathetic  character  are  the  following :  Features  sometimes 
flushed,  sometimes  pallid,  and  sometimes  of  a  leaden  hue ;  lower 
eyelids  swollen,  and  sometimes  surrounded  by  a  blue  semicircle ; 
thirst,  nausea,  or  even  vomiting ;  appetite  diminished,  or  entirely 
lost,  or,  on  the  other  hand,  augmented ;  breath  foul ;  papillae  of 
the  tongue  red  and  projecting  ;  pulse  accelerated  and  irregular. 
Rilliet  and  Barthez  state  that  they  observed  this  irregularity  in 
a  boy  three  years  old,  at  the  time  he  was  passing  a  large  number 
of  lumbrici.  The  irregularity  afterwards  disappeared.  Accele- 
ration of  the  pulse  is  one  of  the  most  common  symptoms  of  these 
worms.  The  popular  idea  of  "  worm  fever"  has  indeed  a  founda- 
tion in  fact.  This  fever  is  often  remittent  and  mild,  but  occasion- 
ally it  is  continuous  and  intense. 

The  symptoms  pertaining  to  the  nervous  system  are  important. 
In  mild  cases  they  may  be  absent,  as  when  there  are  few  lumbrici, 
and  the  child  is  robust,  and  over  the  age  of  five  years,  but  in 
severe  cases  more  or  fewer  of  these  symptoms  are  commonly  present. 
They  are  dilation  of  the  pupils,  especially  inequality  of  dilation,  to 
which  Munro  attached  diagnostic  value ;  strabismus,  twitching  of 
the  muscles,  clonic  convulsions,  somnolence,  headache,  neuralgic 
pains,  delirium.  Rarely  chorea,  deafness,  and  paralysis,  it  is  be- 
lieved, may  result.  (M.  Bouchut,  Gaz.  des  Hopitaux,  1867.)  Hy- 
persesthesia  of  the  abdominal  surface  was  present  in  a  case  which 
I  attended,  and  which  subsided  as  soon  as  the  lumbrici  were  ex- 
pelled. Grinding  the  teeth  in  sleep,  and  picking  the  nostrils,  are 
symptoms  to  which  families  attach  great  value.  Observations, 
however,  show  that,  though  sometimes  due  to  worms,  they  more  fre- 
quently have  another  cause. 

The  local  symptoms  or  disorders,  in  other  words  those  having 
a  mechanical  origin,  are  colicky  pains,  experienced  chiefly  in  the 
umbilical  region ;  in  some  patients,  simple  non-inflammatory  diar- 


640  INTESTINAL    WORMS. 

rhoea  ;  in  others,  enteritis  ;  and  in  others  still,  colitis  ;  stools  some- 
times natural ;  in  other  cases,  liquid  but  fecal ;  and  in  others  still, 
muco-sanguineous  ;  flatulence.  M.  Davaine,  at  a  recent  period, 
made  the  important  discovery  that  the  feeces  of  patients  aftected 
with  worms  contain  the  ova  of  the  particular  species  present,  in 
large  numbers.  The  ovum  of  the  lumbricus  is  oval  and  granular, 
while  that  of  the  trichocephalus  is  spherical,  with  a  small  projec- 
tion at  each  end,  those  of  the  threadworm  oval  and  irregular,  and 
those  of  the  taenia  round.  These  ova  can  be  seen  through  a  lens 
magnifying  150  diameters. 

In  exceptional  cases,  there  are  local  symptoms  due  to  the  pre- 
sence of  worms  in  unusual  situations,  such  as  a  crawling  sensation 
in  the  oesophagus;  a  sense  of  constriction  in  this  tube  or  the 
pharynx;  nausea  and  vomiting;  a  cough,  especially  if  the  worm 
has  crawled  to  the  upper  part  of  the  oesophagus;  rarely  the  most 
urgent  dyspnoea,  and  probable  suflbcation,  if  a  lumbricus  has 
entered  the  larynx. 

The  enteritis  and  colitis,  to  which  these  worms  sometimes  give 
rise,  is  ordinarily  mild,  but  in  rare  instances  ulceration  occurs, 
which  ma}^  be  attended  by  profuse  and  even  fatal  hemorrhage. 
Occasionally  very  painful  and  dangerous  constipation  results  from 
an  accumulation  of  worms,  in  a  ball  or  mass,  too  large  to  be  ex- 
pelled, unless  with  much  delay  and  suffering,  preventing  the  pas- 
sage of  faecal  matter,  and  producing  severe  abdominal  pains.  The 
symptoms  in  these  cases  resemble  closely  those  of  intussusception. 
A  marked  example  of  constipation  produced  in  this  way  occurred 
in  a  family  with  whom  I  am  acquainted,  and  who  then  resided  in 
the  interior  of  this  State.  A  little  girl  of  three  or  four  years  was 
suddenly  affected  with  obstinate  constipation.  The  physicians 
prescribed  active  purgatives,  calomel  among  others,  and  finally 
croton  oil,  and  various  injections,  without  relief.  There  was  great 
pain,  with  distension  of  the  abdomen,  and  death  seemed  inevitable, 
when,  after  the  lapse  of  several  days,  a  free  evacuation  occurred, 
and  in  the  stool  was  a  mass  of  worms  firmly  intertwined. 

Children  often  have  lumbrici  without  any  appreciable  impair- 
ment of  the  general  health,  but  their  presence  may  intensify  the 
symptoms  of  intercurrent  diseases,  and  greatly  increase  the  danger. 
Thus,  I  recollect  two  children  of  three  and  three  and  a  half  years, 
with  pneumonitis,  who,  at  the  same  time,  had  lumbrici,  one  passing 
in  the  course  of  a  few  days  thirty  and  the  other  twelve  of  these 
entozoa.  Both  presented  well-marked  physical  signs  of  pneumo- 
nitis, and,  though  they  recovered,  the  febrile  movement  and  nervous 


DIAGNOSIS.  641 

symptoms  wore  <apparently  aggravated  by  the  intestinal  affection. 
One  had  convulsions  in  the  commencement  of  the  inflammation, 
followed  by  profound  stupor  and  amaurosis,  lasting  two  or  three 
days. 

Often  the  symptoms  due  to  lumbrici  coexist  with  those  of  a 
protracted  and  distinct  intestinal  disease.  Thus,  as  we  have  seen, 
the  intestinal  secretions  of  typhoid  fever  and  of  chronic  diarrha^al 
maladies  afford  a  nidus  for  the  growth  of  worms,  and  accordingly, 
at  an  advanced  stage  of  these  diseases,  lumbrici  are  common. 

The  symptoms  produced  by  the  ascaris  vermicularis  are  somewhat 
different.  These  worms  do  not  usually  cause  the  fever,  disturbed 
digestion,  the  colicky  pains,  or  the  dangerous  nervous  symptoms 
which  arise  from  the  presence  of  lumbrici.  Nor  do  they,  like  lum- 
brici, endanger  life  by  crawling  into  unusual  situations.  Convul- 
sions have  been  attributed  to  them,  but  such  a  result  is  exceptional, 
if,  indeed,  the  cause  was  rightly  assigned. 

The  most  common  symptom  produced  by  the  ascaris  vermicularis 
is  an  intense  itching  of  the  anus.  This  is  most  intense  at  night 
when  the  child  is  in  bed.  It  is  sometimes  absent  during  the  day, 
but  it  returns  so  regularly  at  night,  from  the  increased  activity  of 
the  worm,  that  it  has  even  been  mistaken  for  a  periodical  nervous 
affection,  and  treated  as  such  by  quinine.  So  eminent  a  physician 
as  M.  Cruveilhier  confesses  that  he  has  made  this  mistake.  The 
itching  sometimes  leads  to  onanism,  and  in  the  female  child  the 
ascaris  occasionally  passes  from  the  rectum  to  the  vagina,  where  it 
gives  rise  to  leucorrhoea. 

The  trichocephalus  dispar  and  the  taenia  are  so  rare  in  childhood, 
that  few  physicians  ever  meet  a  case.  The  trichocephalus  is  said 
by  some  to  produce  no  symptoms.  The  symptoms  due  to  taenia  in 
children  are  not  different  from  those  in  the  adult. 

Diagnosis. — Bremser  long  since  made  the  remark,  and  it  has 
been  repeated  by  most  writers  on  diseases  of  children,  that  there 
is  no  sign  or  symptom  which  affords  positive  proof  of  the  presence 
of  intestinal  worms,  except  the  expulsion  of  one  or  more.  Late 
microscopic  investigations  have  revealed,  however,  a  pathognomonic 
sign,  namely,  the  presence  of  ova  in  the  faeces,  which  indicate  not 
only  the  nature  of  the  disease,  but  the  species  of  the  worm. 

The  symptoms  and  disorders  produced  by  lumbrici  may  all  occur 
from  other  causes.  Still,  if  several  of  them  are  present,  and  a 
careful  examination  discloses  no  other  cause,  the  presence  of  worms 
should  be  suspected,  provided  the  child  is  over  the  age  of  two 
years.  The  microscope  may  then  be  used  for  diagnosis.  A  little 
41 


64:2  INTESTINAL    WORMS. 

tentative  treatment,  entirely  safe  to  the  cliild,  will  also  deter- 
mine whether  the  suspicion  is  correct.  One  or  two  doses  of  medi- 
cine, administered  under  such  circumstances,  like  the  surgeon's 
exploring  needle,  may  reveal  the  nature  of  the  disease,  and  indicate 
the  means  of  cure. 

In  Qase  of  the  ascaris  vermicularis,  the  itching  directs  attention 
to  the  anus  as  the  place  of  the  disease,  and  here  the  offending 
entozoa  may  often  he  discovered  by  the  eye. 

Prognosis. — Intestinal  worms  produce  a  fatal  result  in  only  a 
small  proportion  of  cases.  The  ascaris  vermicularis  never  proves 
fatal,  unless  in  rare  instances,  through  convulsions.  The  manner 
in  which  death  may  be  produced  by  lumbrici  has  already  been 
pointed  out. 

In  general,  when  the  nature  of  the  disease  is  ascertained,  the 
worms  are  readily  expelled  by  treatment,  and  the  patient  restored 
to  health.  If  then  there  is  no  complicating  disease,  the  prognosis 
is  good. 

Treatment. — Much  injury  has  been  done  to  children  by  the  use 
of  anthelmintics  occasionally  employed  by  physicians,  but  oftener 
by  parents  before  the  physician  is  called.  Medicines  of  this  kind 
are  usually  irritants,  and,  in  many  of  those  diseases  which  simu- 
late the  verminous  affection,  but  are  distinct  from  it,  there  is 
already  an  irritated  if  not  an  inflamed  state  of  the  intestinal 
mucous  surface. 

Vermifuges  administered  under  such  circumstances  obviously 
do  harm,  and  in  all  acute  diseases  in  which  they  are  not  required, 
even  if  their  action  is  harmless,  their  employment  is  to  be  regretted, 
since  it  consumes  time  which  is  very  precious.  It  is  thus  that 
many  lives  are  lost  by  the  use  of  anthelmintic  nostrums,  which 
are  extensively  advertised  and  which  command  a  ready  sale,  since 
the  belief  in  the  presence  of  worms  as  a  frequent  cause  of  disease 
pervades  all  classes  of  the  community. 

A  safe  rule,  followed  by  many  physicians,  and  it  would  be  much 
better  if  it  were  general,  is  not  .to  give  anthelmintics  unless  the 
child  has  passed  one  or  more  worms,  or  their  ova  are  found  in  the 
faeces,  and  not  then  if  the  symptoms  seem  to  be  referable  to  a  co- 
existing disease.  In  doubtful  cases  in  which  the  symptoms  re- 
semble those  of  worms,  a  purgative  dose  of  calomel  or  calomel 
and  rhubarb  may  be  employed.  It  will  generally  bring  away  one 
or  more  lumbrici  or  a  mass  of  ascaris  vermicularis,  if  either  species 
of  entozoa  is  present.  This  j)urgative  may  be  safely  employed  if 
there  is  no  jjrevious  diarrhoea  or  debility.     If  after  one  or  two 


TEEATMENT.  643 

(loses  and  a  free  purgation  no  worms  arc  passed,  anthelmintic 
remedies  should  not  be  given,  for  it  is  almost  certain  that  no 
worms  exist. 

A  large  number  of  medicines  have,  or  have  had,  a  reputation  as 
anthelmintics.  Santonin,  the  active  principle  of  the  European 
wormseed,  is  one  of  the  best,  and  is  much  employed  in  this  country 
and  in  Europe.  It  is  nearly  tasteless;  it  may  be  given  in  powder, 
spread  on  bread  with  the  butter.  It  is  kept  in  shops  in  one  or 
two  grain  lozenges,  with  and  without  calomel.  It  has  the  ad- 
vantage of  easy  administration,  and  is  destructive  to  both  the 
round  and  threadworm.  M.  Bouchut  considers  it  preferable  to  all 
other  remedies  in  the  treatment  of  the  round  worm.  "  To  children 
two  years  of  age  he  administers  it  in  doses  of  ten  centigrammes 
(2.30  grains),  and  in  patients  above  this  age,  the  quantity  is  in- 
creased by  five  centigrammes  (1.15  grains)  for  every  additional 
year."  He  gives  in  addition  occasional  doses  of  calomel  or  castor 
oil.  In  this  country  santonin  is  usually  administered  in  one  to 
three  grain  doses,  two  or  three  times  daily,  with  an  occasional 
purgative.  The  purgative  is  required  to  aid  not  only  in  the  ex- 
pulsion of  the  worm  but  also  of  the  ova.  In  overdoses  santonin 
causes  vomiting,  diarrhoea,  and  altered  vision,  so  that  objects  ap- 
pear yellow,  but  in  medicinal  doses  it  produces  no  unpleasant  con- 
sequences. Other  medicines  are  preferable  if  there  are  symptoms 
of  enteritis.  For  many  years  the  anthelmintic  most  employed  in 
this  country  was  the  pinkroot,  the  root  of  the  Spigelia  marilandica, 
an  indigenous  plant.  It  was  not  only  prescribed  by  physicians, 
but  employed  by  families  as  a  domestic  remedy.  It  is  apt  to  cause, 
if  the  dose  is  large,  cerebral  symptoms,  as  vertigo,  dimness  of  sight, 
spasm  of  the  facial  muscles,  stupor,  and  even  convulsions.  These 
eifects  less  frequently  occur  if  the  pinkroot  is  given  with  a  purga- 
tive, and  it  has  been  customary  to  administer  it  in  combination 
with  senna  in  an  infusion.  A  half  ounce  of  spigelia  with  an  equal 
quantity  of  senna  is  macerated  for  two  hours  in  a  pint  of  boiling 
water,  and  then  strained.  For  a  child  two  or  three  years  old,  the 
dose  is  half  an  ounce  to  one  ounce.  So  popular  has  this  vermifuge 
been  in  this  country,  that  probably  a  majority  of  the  native-born 
adults  in  the  States  recollect  the  nauseating  doses  of  pinkroot 
administered  by  anxious  parents.  Pharmacy  now  provides  us 
with  the  same  medicine  in  a  more  convenient  and  acceptable 
form,  that  of  the  fluid  extracts. 

I^.  Fluid  ext.  spigel.  fgj  ; 

Fluid  ext.  senna;  f5ss.     Misce. 
One  teaspoonful  to  a  child  from  three  to  five  years. 


644  INTESTINAL    WORMS. 

The  officinal  fluid  extract  of  spigelia  and  senna  may  be  given  in 
the  same  dose.  Prof.  Proctor  recommended  the  addition  of  san- 
tonin to  this  extract. 

^.  Fluid  ext.  spigel.  et  sennse  f§  ; 
Santonin  gr.  viij.     Misce. 

This  is  probably  the  best  anthelmintic  that  can  be  employed  for 
the  destruction  of  the  round  worm  in  uncomplicated  cases,  and  it 
is  also  very  useful  in  treating  the  ascaris  vermicularis.  Chenopo- 
dium  is  also  a  good  anthelmintic.  It  is  efficient,  and  at  the  same 
time  one  of  the  safest  in  case  the  mucous  membrane  is  inflamed. 
If  there  is  abdominal  tenderness,  with  stools  too  frequent,  and  thin, 
or  mucous,  and  tinged  with  blood,  I  should  prefer  the  chenopodium 
to  most  of  the  other  vermifuges.  To  a  child  of  three  years  five 
drops  of  the  oil  may  be  given  three  times  daily.  It  may  be 
continued  for  a  longer  period  than  would  be  safe  for  most  of  the 
other  vermifuges.  Twice  a  week,  during  its  use,  a  mild  purgative 
should  be  given,  as  castor  oil,  rhubarb,  or  magnesia,  unless  the 
bowels  are  open.  It  may  be  given  dropped  on  sugar  or  in  a 
mucilaginous  mixture. 

Dr.  J.  F.  Meigs  says:  "I  myself  rarely  give  any  other  remedy 
than  wormseed  oil  in  slight  and  especially  in  doubtful  cases,  unless 
this  has  already  been  tried  and  failed.  From  my  own  experience, 
I  believe  that  this  remedy  is  all-sufficient  in  a  large  majority  of 
the  cases  that  occur  in  this  city,  as  these  are  almost  always  of  a 
mild  character,  and  as  it  not  only  produces  the  expulsion  of  the 
parasites  when  they  exist,  but  also  acts  beneficially  upon  the  forms 
of  digestive  irritation  which  simulate  so  closely  the  symptoms 
produced  by  worms.  I  am  persuaded,  indeed,  that  of  all  the  cases 
that  have  come  under  my  notice,  in  which  it  seemed  probable  that 
worms  might  be  present,  none  were  expelled  in  nearly  half,  and 
yet  the  signs  of  disturbed  health  have  passed  away  under  the  use 
of  the  remedy."  ....  "The  following  is  a  very  good  formula  for 
the  administration  of  this  remedy : — 

"B.  01.  cbenopodii  gtt.  Ix  vel  3j ; 
P.  g.  acacige  SU  ; 
Syrup,  simplic.  .^j  ; 
Aq.  cinnamom.  5ij.     Misce. 
Give  a  dessertspoonful  three  times  a  day  for  three  days,  and  repeat  after  several 
days." 

In  cases  of  protracted  intestinal  disease  attended  by  an  increased 
and  vitiated  secretion  from  the  mucous  surface,  a  state  which  often 
gives  rise  to  worms,  turpentine  is  one  of  the  best  anthelmintics. 


TREATMENT.  645 

In  fact,  in  some  of  these  cases,  there  is  no  good  substitute  for  it. 
For  example,  ti  boy  of  about  ten  years,  attended  by  myself, 
October,  1864,  had  reached  or  nearly  reached  the  fourth  week  of 
•  typhoid  fever,  when  he  passed  from  his  bowels  a  large  quantity  of 
blood.  He  was  j^reviously  emaciated  and  weak,  and  there  had 
been,  as  is  usual  in  such  cases,  considerable  diarrhoea.  The 
hemorrhage  was  attended  with  great  prostration,  from  which, 
however,  he  partially  rallied  by  the  use  of  stimulants.  On  the 
following  day  an  equally  severe  hemorrhage  occurred,  attended 
with  coldness  of  the  face  and  extremities  and  great  feebleness  of 
pulse,  so  that  death  appeared  imminent.  Turpentine  was  now 
administered  every  six  hours,  a  few  lumbrici  were  passed,  and  the 
case  thenceforth  progressed  ftivorably.  The  mechanical  effect  of 
the  lumbrici  on  the  ulcerated  surface  of  intestine  had  probably 
given  rise  to  the  hemorrhage.  Turpentine  may  be  given  in  doses 
of  from  five  to  ten  minims  three  times  daily  to  a  child  five  years 
old.  Sweetened  milk  or  sugar  in  powder  is  a  good  vehicle  for  it, 
or  it  may  be  given  in  a  mucilaginous  mixture. 

I^.  Spts.  terebinth,  rect.  5ij  ; 
01.  limonis  gtt.  v ; 
Miicil.  gum  acac, 
Syr.  simplic,  aa  3vj  ; 
Aq.  anisi  §j.     Misce. 
Dose,  one  teaspoonful  every  six  liours. 

The  following  •  formula  for  the  employment  of  this  agent  is 
recommended  by  Dr.  Condie: — 

R.     Mucil.  gum  acac.  §ij ; 
Sacch.  alb.  5  s ; 
Spir.  aether,  nitr.  5iij  ; 
Spir.  terebinth,  rect.  giij  ; 
Magnes.  calcinat.  9j  ; 
Aquse  menthse  §j.     Misce. 

It  is  useless  to  enumerate  the  many  anthelmintic  mixtures  which 
have  been  extolled  from  time  to  time.  Those  mentioned  above 
are  the  least  nauseous,  and  will  rarely  disappoint  the  practitioner. 
One  other  antidote  for  the  round  worm  should  be  mentioned,  as  it 
has  been  much  used  and  is  efiicient,  namely,  cowhage.  This  con- 
sists of  the  bristles  which  cover  the  pods  of  the  Mucuna  jn-uriens, 
a  tropical  plant.  The  pods  are  dipped  in  plain  syrup  of  the  ordi- 
nary consistence,  and  the  bristles  are  scraped  ofi:'  with  the  syrup. 
When  enough  of  the  medicine  is  added  to  render  the  syrup  of  the 
consistence  of  thick  honey,  it  is  ready  for  use.  The  dose  is  a  tea- 
spoonful  every  morning  for  three  days,  after  which  a  cathartic 


64iQ  GASTRO-INTESTINAL    HEMORRHAGE. 

should  be  administered.  I  have  never  prescribed  cowhage,  although 
it  is  not  unfrequently  ordered  by  physicians,  and  a  popular  nostrum 
consists  chiefly  of  it. 

•Threadworms  require  different  treatment.  The  anthelmintics 
described  above  have  less  effect  on  them  than  on  the  lumbrici. 
Still,  they  may  be  administered  for  the  expulsion  of  the  former, 
but  rather  as  adjuvants  to  the  main  treatment.  The  main  treat- 
ment should  be  local,  consisting  in  the  use  of  injections,  since  from 
the  habitat  of  this  worm  enemata  will  ordinarily  reach  and  destroy 
it.  The  substances  which  have  been  successfully  employed  as 
enemata  are  salt  and  water,  lime-water,  a  decoction  of  aloes,  or  a 
decoction  of  two  cloves  of  garlic  in  milk.  West  recommends  the 
injection  of  six  ounces  of  lime-water  and  two  drachms  of  tincture 
ferri  chloridi.     Trousseau  uses  a  solution  of  the  arsenite  of  soda. 

^.     Sodfe  arsenit.  gr.  j  ; 
Aq.  destillat.  §xij.     M. 

For  six  enemata,  one  or  two  daily. 

Cold  injections  are  more  effectual  than  warm,  and  even  a  daily 
injection  of  cold  water  has  sometimes  been  found  sufficient  to 
effect  a  cure  with  proper  internal  remedies. 

Threadworms  in  the  rectum  may  also  be  destroyed  by  ointments 
containing  mercury,  as  a  drachm  of  mercurial  ointment  mixed 
with  oil  or  melted  butter,  or  five  grains  of  calomel  with  the  yelk 
of  an  egg.  (Bouchut.)  After  the  expulsion  of  the  worms  patients 
often  require  tonic  treatment.  In  the  treatment  of  taenia  in  chil- 
dren the  pumpkin-seed  is  a  safe  and  efficient  remedy,  and  is  the 
one  now  commonly  employed. 


CHAPTER    XII. 

GASTRO-INTESTINAL  HEMORRHAGE. 

Hemorrhage  from  the  capillaries  is  more  frequent  in  infancy  than 
at  any  other  period  of  life,  whether  in  consequence  of  the  irregu- 
larity of  the  circulation  and  frequent  congestions  in  the  infant, 
or  the  greater  delicacy  and  feebleness  of  the  minute  vessels  at 
this  age.  Hemorrhage,  generally  capillary,  from  the  gastro-intes- 
tinal  mucous  surface,  occurs  sufficiently  often  in  the  child,  and 
especially  in  the  infant,  to  render  it  a  disease  of  some  importance. 
It  is  more  frequent  the  younger  the  individual. 

This  hemorrhage  occurs  in  three  distinct  pathological  states: 


GASTRO-INTESTINAL    HEMORRHAGE.  647 

first,  in  the  iicw-borii  infant  from  causes  not  fully  ascertained  ; 
secondly,  frrtm  a  pathological  state  of  the  blood  or  the  vessels  in 
which  it  circulates,  and  which  is  often  connected  with  purpura 
hemorrhagica  ;  thirdly,  from  a  local  cause. 

First  Variety. — In  49  cases,  which  I  have  collected  from  different 
writers,  the  hemorrhage  occurred  in  38  under  the  age  of  six  days, 
in  5  from  six  to  ten  days,  and  in  6  from  ten  to  twenty  days.  Some 
authors  cite  cases  which  occurred  at  the  age  of  several  weeks,  but 
hemorrhage  into  the  intestines  at  so  late  a  period  cannot  be  due  to 
any  cause  operating  at  birth,  and  it  is  proper  to  consider  such  as 
examples  of  one  of  the  other  varieties. 

Passive  congestion  of  the  gastro-intestinal  mucous  membrane  is 
not  infrequent  in  the  new-born.  Billard  speaks  of  twenty-five  cases 
without  hemorrhao;e  which  he  has  examined.  This  anatomical 
state  of  the  mucous  membrane  of  the  intestines,  whether  occurring 
as  part  of  a  general  plethora  or  being  simply  a  local  affection  with 
no  hyperemia  of  other  parts,  evidently  requires  only  a  certain  in- 
crease and  hemorrhage  inevitably  results. 

The  cause  of  the  abnormal  congestion  of  the  gastro-intestinal 
mucous  membrane,  so  common  in  the  new-born,  has  been  referred 
by  writers  to  the  previous  health  of  the  parents,  to  circumstances 
attending  the  birth,  especially  too  prompt  a  ligature  of  the  cord, 
to  irritant  matters  in  the  intestines,  to  external  violence,  and  to  the 
two  opposite  extremes,  namely,  a  plethoric  and  a  feeble  state.  In 
my  opinion,  the  chief  cause,  in  many  cases,  is  the  tardy  or  incom-  . 
plete  establishment  of  the  respiratory  and  circulatory  functions, 
which  gives  rise  to  congestion  in  the  cavities  of  the  heart  and  in  the 
lungs,  and,  consequently,  in  the  capillaries  of  the  systemic  system. 
Evidently,  this  congestion  is  most  intense  in  the  full-blooded.  Bil- 
lard says,  of  fifteen  cases  of  intestinal  hemorrhage  which  he  ex- 
amined, most  of  them  were  remarkable  for  the  plethoric  condition 
of  their  bodies  and  the  general  congestion  of  their  integuments. 
Some,  on  the  contrary,  were  pale  and  feeble,  as  is  common  after 
abundant  hemorrhage. 

In  two  infants  who  died  soon  after  birth,  and  whose  bodies  I 
subsequently  examined,  there  was  apparently  a  plethoric  state, 
which  rendered  the  fatal  result  more  certain,  if  it  did  not,  indeed, 
produce  it.  In  one  of  these,  in  addition  to  intense  general  conges- 
tion, meningeal  apoplexy  had  occurred,  although  the  birth  of  the 
child  had  been  easy. 

It  is  not  difiicult  to  understand  in  what  way  too  speedy  a  liga- 
ture of  the   cord   may  be  a  cause  of   capillary  congestion   and 


648  GASTRO-TNTESTINAL    HEMORRHAGE. 

hemorrhage.  At  the  moment  of  birth,  the  uterus  is  contracted, 
the  placenta  compressed,  and,  if  the  cord  is  now  tied,  more  blood 
remains  in  the  vessels  of  the  infant  than  if  tied  a  little  later,  A 
little  later,  in  consequence  of  the  temporary  cessation  of  uterine 
contractions,  and  the  re-establishment  of  circulation  in  the  infant, 
blood  flows  through  the  cord  towards  the  placenta.  The  cord 
thus  acts  as  a  safety  valve  to  the  circulation.  Any  accoucheur 
who  will  take  pains  to  witness  the  effect  on  the  cord  of  the  return 
of  circulation,  will  observe  what  I  have  stated.  Too  speedy  a 
ligature  of  the  cord  would  not,  however,  be  sufiicient  in  the  ma- 
jority of  cases  to  produce  that  amount  of  plethora  which  would  give 
rise  to  intestinal  hemorrhage  without  other  co-operating  causes. 

Tardy  or  incomplete  establishment  of  respiration  and  circula- 
tion, which  gives  rise  to  intestinal  congestion  and  hemorrhage, 
may  be  due  to  disease  of  the  heart  or  lungs,  as  atelectasis  or 
cyanosis,  to  feebleness  of  the  infant,  or  to  slow  and  difficult  birth. 
In  a  large  proportion  of  cases,  however,  the  birth  is  easy.  Thus, 
three  of  five  patients  with  intestinal  hemorrhage,  who  were  treated 
by  ]\I.  Gendrin,  were  born  of  an  easy  labor,  and  the  same  was  true 
of  four  infants  observed  by  M.  Kiwisch. 

The  second  variety  of  gastro-intestinal  hemorrhage  often  occurs 
as  a  sequel  of  other  and  debilitating  diseases.  I  have  known  it 
to  occur  as  a  sequel  of  measles,  smallpox,  scarlet  fever,  and  in  one 
case  of  typhoid  fever.  One  of  these  patients,  when  apparently 
the  period  of  danger  was  passed,  began  to  lose  blood  from  nearly 
all  the  mucous  surfaces,  from  the  nostrils  and  gums,  as  well  as 
intestines,  and  the  case,  which  but  for  the  hemorrhage  would 
doubtless  have  had  a  favorable  issue,  terminated  fatally  in  less 
than  a  week. 

Patients  with  this  variety  of  gastro-intestinal  hemorrhage  some- 
times present  the  maculae  of  purpura,  and  commonly  their  aspect 
is  pallid  and  cachectic.  The  following  was  a  fatal  case  of  hemor- 
rhage occurring  from  the  ileum,  in  a  mild  form  of  purpura  hemor- 
rhagica : — 

Case. — An  infant,  eight  months  old,  of  healthy  parentage,  nursing, 
with  no  previous  sickness,  and  flesh}',  vomited  a  small  quanty  of  blood 
on  the  25th  of  March,  1865;  soon  after  it  passed  a  stool  consisting  of 
almost  pure  blood.  On  the  following  day  five  or  six  patches  of  pur- 
pura hemorrliagica  were  observed  on  the  arms  and  legs.  These  maculiB 
continued  till  death.  There  was  no  more  haematemesis,  but  the  stools, 
which  were  from  two  to  four  daily,  consisted  largely  of  blood.  Death 
occurred  from  exhaustion  on  March  31st. 

Secfio  Cadaver. — Head  not  examined;  thoracic  organs  health3%  but 
pale ;  liver  fatty ;  stomach,  upper  part  of  small  intestines,  and  entire  colon 


GASTRO-INTESTINAL    HEMORRHAGE.  6-19 

of  normal  appearance,  unless  presenting  a  somewhat  lighter  color  than 
the  healthy  intestine  from  deficiency  of  blood;  mucous  membrane  in 
the  ileum  to  tlie  extent  of  several  inches,  intensely  injected  without 
thickening.  The  blood  had  obviously  escaped  from  this  portion  of  the 
intestine,  and  a  moderate  amount  of  this  fluid  was  found  in  the  tube 
below  the  point  of  vascularity.  This  case  is  interesting  not  only  on 
account  of  the  development  of  purpura  hemorrhagica,  but  the  subse- 
quent meloBna  in  a  nursing  child,  apparently  of  healthy  parentage,  and 
without  previous  sickness. 

In  our  remarks  on  internal  convulsions,  the  case  is  related  of  a 
scrofulous  infant  who,  to  all  apj)earance  in  her  ordinary  health, 
suddenly  became  affected  with  intestinal  hemorrhage  in  connec- 
tion with  external  and  internal  convulsions.  A  point  of  interest 
in  this  case  was  the  relation  of  the  hemorrhage  to  the  neurosis. 
In  one  of  the  three  cases  of  intestinal  hemorrhage  described  by 
West,  there  were  also  convulsions.  In  rare  instances  there  is  an 
hereditary  hemorrhagic  diathesis  to  which  the  melfena  is  attribu- 
table. In  the  NeiD  York  Journal  of  Medicine  and  Surgery^  July, 
1840,  Prof.  Swett  relates  the  history  of  a  hemorrhagic  family. 
Seventeen  out  of  eighteen  children  of  this  family  had  died  of 
hemorrhage  of  one  form  or  another,  and  the  survivor  had  epistaxis 
and  melpena. 

In  the  third  variety,  among  the  local  causes  producing  hemor- 
rhage may  be  mentioned  ulceration  as  in  typhoid  fever,  or  in 
severe  intestinal  inflammation,  the  mechanical  eflect  of  solid  sub- 
stances, lumbrici,  invagination,  obstruction  to  the  portal  circula- 
tion, polypus  of  the  rectum.  Occasionally  at  the  post-mortem 
examination  of  young  infants  I  have  found  blood  with  mucus  in 
the  duodenum  and  jejunum,  these  portions  of  the  intestines  being 
at  the  same  time  intensely  congested.  In  one  case  of  protracted 
entero-colitis  occurring  in  the  summer  season,  I  found  many  small 
circular  ulcers  in  the  colon,  nearly  all  containing  points  of  extra- 
vasated  blood.  Such  are  the  principal  local  causes  of  hemorrhage 
from  the  bowels.  Ordinary  colitis  may  also  be  considered  a  cause, 
although  the  amount  of  blood  evacuated  in  this  disease  is  commonly 
small. 

Of  the  three  forms  of  intestinal  hemorrhage  described  above, 
that  arising  from  local  causes  is  most  frequent,  while  that  occur- 
ring from  a  purpuric  or  hemorrhagic  diathesis  is  least  frequent. 
In  rare  cases  fatal  intestinal  hemorrhage  may  occur  in  the  new- 
born, and  the  blood  be  retained  in  the  intestine,  or  if  passed  it 
may  so  closely  resemble  the  meconium  that  its  true  nature  is  not 
discovered.     M.  Bednar   relates  the  following   case  {Krankheitcn 


650  GASTRO-INTESTINAL    HEMORRHAGE. 

der  Neugebornen) :  "  On  the  eleventti  day  after  birth,  the  boy's 
skin  (then  of  a  pale  yellow  color)  diminished  in  warmth,  the  im- 
pulse of  the  heart  became  dull  and  prolonged,  the  respiratory 
murmur  scarcely  perceptible.  The  child  lay  almost  motionless 
and  slumbering.  The  day  following  the  surface  could  scarcely 
be  kept  warm,  and  the  little  patient  had  to  be  aroused  to  suck. 
On  the  twentieth  day  after  birth  it  died.  The  brain  was  found 
to  be  anaemic,  the  lungs  plethoric,  whilst  blood  was  eflused  into 
the  duodenum  and  stomach." 

Melfena  is  more  frequent  than  heematemesis.  The  hemorrhage, 
excej^t  when  produced  by  a  local  cause,  is  usually  from  the  small 
intestines.  The  blood,  unless  it  comes  from  a  point  near  the 
anus,  as  the  rectum  or  descending  colon,  is  commonly  dark,  and 
sometimes  partially  decomposed,  emitting  an  offensive  odor.  Ad- 
mixture of  the  blood  with  the  intestinal  secretions  prevents  coagu- 
lation of  the  fibrin. 

Gastro-intestinal  hemorrhage  in  itself  produces  few  symptoms 
aside  from  the  prostration  which  attends  all  hemorrhages.  The 
disease  with  which  it  is  associated  may  give  rise  to  many  and 
severe  symptoms. 

Prognosis. — The  result  in  the  first  and  second  varieties  is  much 
more  unfavorable  than  in  the  third.  Many  new-born  infants 
affected  with  gastro-intestinal  hemorrhage  die,  but  some  recover. 
Billard  attended  fifteen  fatal  cases.  It  is  probable,  however,  that 
death  in  the  first  variety  is  often  due  more  to  some .  coexisting 
lesion,  than  to  the  intestinal  hemorrhage.  Meningeal  apoplexy, 
and  the  incomplete  establishment  of  the  circulatory  and  respiratory 
functions,  may  both  operate  as  direct  causes  of  death  in  this  variety. 

In  the  second  variety,  also,  a  very  guarded  prognosis  should 
be  given ;  so  great  a  change  in  the  circulatory  system  as  to  cause 
rupture  of  the  capillaries,  or  transudation  of  blood  in  the  ordi- 
nary course  of  the  circulation,  is  a  serious  state.  When  this  he- 
morrhage occurs  as  a  sequel  of  the  eruptive  fevers,  or  in  purpura 
hemorrhagica,  the  patient  is  more  apt  to  die  than  recover. 

In  the  third  form  of  intestinal  hemorrhage,  the  result  depends 
on  the  nature  of  the  cause,  whether  it  is  susceptible  of  removal. 
The  majority  of  cases  in  this  variety  recover. 

Treatment. — Billard  recommends,  as  a  means  of  preventing  ca- 
pillary congestion  and  hemorrhage  in  the  new-born,  to  allow  a 
little  blood  to  escape  from  the  umbilical  cord  before  its  ligation, 
if  the  establishment  of  respiration  and  circulation  is  difiicult  or 
incomplete.     This  relieves  the  hypersemia  of  the  internal  organs 


TREATMENT.  651 

and  facilitates  tlic  flow  of  blood.  After  the  commencement  of 
internal  hemorrhage  and  the  appearance  of  bloody  stools,  the  same 
may  bo  done  if  plethora  is  indicated  by  the  florid  and  robust  ap- 
pearance of  the  infant,  and  the  cord  is  not  too  much  shrivelled. 

The  treatment,  both  therapeutic  and  regimenal,  of  intestinal 
hemorrhage  should  vary  according  to  the  age  and  state  of  the 
infant,  the  profuseness  of  the  hemorrhage,  and  the  nature  of  the 
cause.  Perfect  quietude,  in  the  recumbent  position,  is  requisite 
in  all  severe  cases.  Derivation  to  the  extremities,  should  be  pro- 
cured in  the  young  infant,  by  heated  dry  flannel  or  flannel  wrung 
out  of  hot  water ;  in  the  older  infant,  by  the  same,  with  the  addi- 
tion of  mustard.  The  nursing  infant  should  remain  at  the  breast, 
being  allowed,  perhaps,  in  addition  to  the  breast  milk,  a  little  cool 
barley  or  gum-water.  Spoon-fed  infants  should  be  given  food  of  the 
blandest  quality,  in  the  liquid  form  and  cool.  This  is  the  proper 
diet,  whatever  the  age,  in  the  commencement  of  the  hemorrhage. 
If  there  are  evidences  of  exhaustion,  cool  beef-tea,  or  essence,  and 
alcoholic  stimulants,  are  necessary.  It  has  been  advised,  in  certain 
forms  of  intestinal  hemorrhage,  to  apply  leeches  over  the  abdomen 
or  around  the  anus.  This  treatment  would,  in  my  opinion,  rarely 
be  useful,  but,  on  the  contrary,  in  most  cases,  injurious.  Hemor- 
rhage from  a  mucous  surface,  when  once  established,  will  generally 
quickly  relieve  the  local  hypertemia,  and  leeching,  unless  very 
cautiously  employed,  would  promote  the  prostration,  in  which  the 
real  danger  in  this  disease  consists.  On  the  other  hand,  moderate 
counter-irritation  over  the  abdomen  may  be  attended  with  real 
benefit  as  a  derivative. 

The  therapeutic  treatment  consists  mainly  in  the  use  of  astrin- 
gents. Of  the  mineral  astringents,  acetate  of  lead  and  nitrate  of 
silver  have  been  used,  but  the  liquor  ferri  subsulphatis  is  preferable 
to  all  other  astringents  in  hemorrhage  from  the  stomach  and  upper 
part  of  the  small  intestine,  but  it  is  believed  to  be  decomposed  in 
its  passage  through  the  intestine,  so  that  it  has  less  astringent  or 
styptic  effect  in  the  lower  bowel  than  gallic  acid.  It  may  be  given 
to  a  child  five  years  of  age,  in  doses  of  three  or  four  drops  in 
sweetened  water  or  in  mucilage. 

Astringent  enemata  are  sometimes  useful.  M.  Rilliet  treated  a 
case  which  recovered  with  enemata,  each  containing  twelve  grains 
of  extract  of  rhatany,  a  strong  decoction  of  the  same  astringent 
being  applied  externally  to  the  abdomen.  M.  Bouchut  recommends 
"cold  water  externally  to  the  abdomen,  internally  by  the  mouth, 
or  by  enemata  frequently  repeated.      These  enemata  should  be 


652  INTUSSUSCEPTION. 

composed  of  two  or  three  large  spoonfuls  only.  They  may  be 
rendered  more  active  with  three  grains  of  tannin,  or  with  seven 
grains  of  the  extract  of  rhatany,  or  seven  grains  of  catechu,  or, 
lastly,  with  one  grain  of  nitrate  of  silver.  In  this  latter  case,  a 
small  glass  syringe  and  distilled  water  must  be  used,  to  avoid  the 
premature  decomposition  of  the  medicine." 

In  the  hemorrhage  occurring  in  purpura,  or  after  exhausting 
constitutional  diseases,  tonics  should  be  given  in  addition  to  astrin- 
gents. In  chronic  inflammatory  disease  of  the  intestinal  mucous 
membrane,  attended  by  a  vitiated  secretion  of  the  follicles,  the 
hemorrhage  may  be  best  treated  by  turpentine.  I  have  elsewhere 
related  two  cases  of  recovery  by  the  use  of  this  agent,  in  one  of 
which  (typhoid  fever)  lumbrici  were  expelled. 

If  the  hemorrhage  is  due  to  a  local  cause,  as  lumbrici  or  a  rectal 
polypus,  the  treatment  obviously  should  consist  in  the  removal  of 
this  cause. 


CHAPTER   XIII. 

INTUSSUSCEPTION. 

Intussusception,  or  the  passage  of  one  portion  of  intestine  into 
another,  has  Ions:  been  known  as  an  occasional  accident.  Hippo- 
crates,  though  debarred  from  the  study  of  morbid  anatomy, 
appears  to  have  had  a  pretty  clear  idea  of  this  lesion,  and  his 
practical  mind  suggested  a  mode  of  treatment  which  has  been 
employed  till  the  present  time. 

Intussusception  without  Symptoms. 

This  is  not  properly  a  disease.  It  consists  in  a  displacement 
without  any  other  anatomical  change.  There  is,  therefore,  no  ob- 
struction, inflammation,  or  even  congestion  present,  and  no  symp- 
toms. This  form  of  invagination  might  ordinarily  be  reduced  by 
the  normal  peristaltic  and  vermicular  movements  of  the  intestine. 

Invagination  of  a  portion  of  the  small  intestine  into  the  part  im- 
mediately below  it  is  often  observed  at  the  post-mortem  examina- 
tion of  young  infants,  who  had  presented  no  symptoms  due  to  the 
displacement.  The  invaginated  mass  is  usually  from  half  an  inch 
to  two  inches  in  length,  and,  as  a  rule,  this  accident  is  multiple. 


INTUSSUSCEPTION    WITH    SYMPTOMS.  653 

There  may  be  ten  or  more  distinct  intussusceptions,  at  distances 
of  a  few  inclies  from  each  other.  This  simple  displacement  is 
believed  to  occur  ordinarily  at  or  a  short  time  prior  to  the  moment 
of  dissolution.  It  has  been  supposed  to  be  most  frequent  in  those 
who  have  died  of  cerebral  or  spasmodic  diseases,  but  its  occurrence 
is  not  unusual  in  other  pathological  states.  I  have  often  found  it 
at  the  post-mortem  examination  of  infants  who  have  had  subacute 
or  chronic  entero-colitis.  Ilevin  states  that  he  has  seen  it  at  the 
Salpetricire  over  three  hundred  times.  Billard  has  seen  it  espe- 
cially in  infants  who  have  been  subject  to  constipation.  Any  irri- 
tant, mechanical  or  other,  which  disturbs  the  regular  movements 
of  the  intestines,  doubtless  may  produce  it.  We  learn,  from  good 
authority,  that  it  can  be  caused  in  the  rabbit  by  irritating  the 
anus.  It  is,  therefore,  probable  that  the  thread  as  well  as  round 
worm,  by  the  irritation  mechanically  produced,  may  be  a  cause. 

It  is  not  improbable  that  simple  intussusception  occasionally 
occurs  temporarily  in  children  whose  health  remains  good,  when 
the  regular  movements  of  their  intestines  are  disturbed  by  irri- 
tating ingesta  or  other  causes.  This  form  of  displacement  never 
takes  place  in  the  large  intestine.  Its  usual  seat  is  the  lower  part 
of  the  jejunum,  and  upper  part  of  the  ileum.  As  it  possesses  little 
interest  as  regards  pathology,  and  none  whatever  as  regards  symp- 
tomatology and  therapeutics,  it  may  be  ignored  in  our  description 
of  intussusception. 

Intussusception  -with  Symptoms. 

Intussusception,  or  invagination,  is  one  of  the  most  painful  and 
dangerous  of  human  maladies,  but  fortunately  not  of  frequent 
occurrence.  I  possess  the  records  of  fifty-two  cases,  which  are 
tabulated  in  the  Appendix  (F) ;  and  from  which  the  principal  facts 
contained  in  this  paper  are  derived.  The  patients  were  under  the 
age  of  twelve  years.  The  statistics  furnished  by  these  records, 
therefore,  relate  to  both  the  periods  of  infancy  and  childhood. 

Previous  Health.— In  thirty-four  of  the  fifty-two  cases,  the 
state  of  the  health  previously  to  the  invagination  was  recorded. 
From  the  following  table  it  is  seen  that  half,  or  seventeen,  were 
previously  well,  the  remaining  half  suffering  from  some  disease  or 
derangement : — 

Previous  Health. 
, « 


"S^-  Good.  Disease  or  Derangement. 

One  year  or  under 15  8 

Over  one  year 3  9 

17  17 


65-i  INTUSSUSCEPTION. 

• 

MM.  Rilliet  and  Barthez,  whose  views  in  reference  to  intussus- 
ception are  derived  from  the  examination  of  the  records  of  twenty- 
five  cases,  state  that  the  previous  health  is  ordinarily  good,  and 
the  disease  is,  therefore,  primitive.  Their  remark,  according  to 
the  above  statistics,  is  seen  to  be  correct  as  regards  patients  under 
the  age  of  one  year,  but  incorrect  for  those  over  that  age. 

Most  of  the  seventeen  who  had  jirevious  ill-health  had  diarrhoea, 
dysentery,  or  constipation,  or  diarrhoea  alternating  with  constipa- 
tion. Of  those  otherwise  affected,  one  had  threadworms,  two 
obscure  abdominal  pains,  one  nausea  and  vomiting,  and  onp  four 
months  old  had  symj^toms  of  invagination,  at  the  age  of  ten  weeks, 
which  soon  passed  oif.  It  is  seen  that  the  pre-existing  affections 
were  ordinarily  such  as  would  be  likely  to  accelerate  the  move- 
ments of  the  intestines  and  at  the  same  time  render  them  irregular. 
Causes. — The  above  statistics,  therefore,  show  that  in  a  pretty 
large  proportion  of  cases  of  intussusception,  there  is  previous  dis- 
ease of  the  intestine  or  derangement  of  its  function.  This,  doubt- 
less, is  a  cause  of  the  displacement  in  at  least  a  certain  proportion 
of  cases.  It  is  proper  to  attribute  a  causative  relation  to  the  diar- 
rhoeal  maladies  and  constipation,  inasmuch  as  they  have  been 
found  to  precede  the  displacement  in  so  many  instances.  From 
the  records,  it  is  probable  that  invagination  with  symptoms,  as 
well  as  the  simple  form,  as  already  stated,  may  be  caused  by  the 
irritation  of  intestinal  worms.  They  were  present  in  three  of  the 
fifty-two  patients,  though  two  of  these  seemed  perfectly  well  till 
the  occurrence  of  the  intussusception.  The  other  patient,  imme- 
diately prior  to  it,  complained  of  soreness  around  the  anus-,  and 
ascarides  were  found  on  examination. 

The  use  of  irritating  and  indigestible  food  is  regarded  by  writers 
as  an  occasional  cause.  Thus,  some  who  have  had  intussusception 
have  been  in  the  habit  of  taking  fruits,  candies,  and  pastries  freely. 
Such  ingesta  may  be  an  immediate  cause  by  their  irritating  eft'ect, 
or  a  remote  cause  giving  rise  to  diarrhea,  which,  in  turn,  produces 
intussusception. 

Itilliet  and  Barthez  consider  the  sex  a  predisposing  cause. 
There  are  more  male  than  female  children  afi'ected  with  intussus- 
ception. Of  the  twenty -five  cases  collated  by  them,  all  but  three 
were  boys.  In  our  own  collection,  the  sex  of  thirty-four  of  the 
patients  was  recorded,  and  of  these  twenty-three  were  boys. 

In  rare  cases  external  violence  is  the  only  apparent  exciting 
cause.  One  patient  (No.  37,  Appendix)  received  a  severe  contusion 
of  the  abdomen  two  years  before  death,  and  from  this  time  con- 


3     " 

4 

3     " 

5 

5     " 

6 

1  was 

7 

1      " 

8 

3  were 

9 

INTUSSUSCEPTION    WITH    SYMPTOMS.  655 

tinned  to  complain  at  intervals  of  jtain  in  the  bowels.  One  writer 
also  mentions  the  case  of  a  child  nine  years  old  who  received  a 
blow  from  a  comrade  at  school,  and  from  this  time  had  alternately 
diarrhcca  and  constipation  till  the  invagination  commenced. 
Rilliet  and  Barthez  also  relate  the  case  of  two  children  who  were 
taken  suddenly  with  invagination  when  their  parents  were  tossing 
them  in  their  arms. 

Age. — Of  the  fifty-two  cases  embraced  in  our  statistics,  the  ages 
were  as  follows: — 

3  were  3  months  old.  1  was  10  mouths  old. 

1    "    11       " 

1  "    12       " 

2  were  from  1  to  3  years  old. 

8     "         "     3  "  5       "       " 
8     "        "     3  "  5       "       " 

3  not  given. 

There  were,  therefore,  no  cases  under  the  age  of  three  months, 
23  cases  between  the  ages  of  three  and  six  months,  or  nearly  one- 
half  of  the  entire  number,  8  from  the  age  of  six  months  to  one 
year,  and  only  18  between  the  ages  of  one  year  and  twelve.  These 
statistics  correspond,  in  the  main,  with  those  of  Rilliet  and  Bar- 
thez, in  whose  collection  of  25  cases  there  was  no  one  under  the 
age  of  four  months. 

The  great  liability  to  intussusception  in  infancy  is  due  partly  to 
the  anatomical  character  of  the  intestine  in  this  period  of  life,  and 
partly,  doubtless,  to  the  fact  that  there  are  more  frequent  irregu- 
larities in  the  intestinal  movements  than  in  older  children.  In 
the  infant  the  walls  of  the  intestines  are  thin,  the  mucous  and 
muscular  coats  and  the  connective  tissue  being  much  less  developed 
than  in  those  that  are  older;  the  mesentery  and  meso-colon  have 
also  greater  depth  as  compared  with  the  same  in  other  periods  of 
life,  except  the  meso-colon  at  the  points  where  it  passes  over  the 
kidneys,  in  which  places  it  is  very  short,  or  even  in  some  cases 
nearly  absent.  Moreover,  the  space  occupied  by  the  large  intes- 
tine, in  which  part  of  the  digestive  tube  intussusception  commonly 
occurs,  is  much  shorter  relatively  to  the  length  of  the  intestine 
than  in  those  that  are  older.  In  about  thirty  measurements,  which 
I  have  made  of  the  length  of  the  large  intestine  and  the  space 
occupied  by  it,  the  latter  was  found,  in  the  average,  about  one- 
third  that  of  the  former,  which,  of  course,  necessitates  doubling 
of  the  intestine  on  itself.  These  peculiarities  of  structure  in  the 
infant  obviously  favor  the  occurrence  of  intussusception. 


656  INTUSSUSCEPTION. 

Seat  and  Pathological  Anatomy. — "While  the  simple  or  reduci- 
ble variety  of  intussusception  is  usually  multiple,  the  irreducible 
form  is  ordinarily  single.  Two  exceptional  cases  will  be  presently 
related.  In  one  case  in  our  table  there  was  a  reducible  in  addition 
to  the  irreducible  invagination. 

"While  the  simple  variety  is  seated  in  the  small  intestine,  the 
seat  of  the  irreducible  form  is,  with  occasional  exceptions,  the 
colon.  The  colon  constitutes  the  entire  invaginated  mass,  or  else, 
and  more  frequently,  it  forms  the  exterior,  while  the  incarcerated 
portion  consists  wholly  or  in  part  of  the  ileum. 

Intussusception  in  the  Small  Intestines. 

Bouchut  says :  "  M.  Rilliet  states,  in  a  recent  treatise,  that  in 
infancy  the  intestinal  invagination  is  always  accomplished  at  the 
exj)ense  of  the  large  intestine,  and  that  there  is  never  invagina- 
tion of  the  small  intestine.  This  is  incorrect.  I  have  observed 
the  small  intestine  invaginated  in  the  adjacent  inferior  j^art.  Taylor 
has  reported  a  case  of  this  kind  in  a  child  twenty  months  old,  who 
died  after  an  attack  of  acute  peritonitis.  M.  Marage  has  seen 
another  case  in  a  child  thirteen  months  old,  who  recovered  after 
having  voided  the  invaginated  portion  furnished  with  two  of  those 
diverticula  so  frequent  in  the  small  intestine  of  the  foetus." 

But  from  all  that  appears,  the  case  reported  by  M.  Marage  may 
have  been,  and  probably  was,  an  example  of  the  common  form  of 
intussusception,  namely,  of  the  ileum  into  the  colon.  I  am  not 
certain  what  case  observed  by  Mr.  Taylor  is  alluded  to,  but  if  it 
is  No.  18  of  our  table,  as  is  probable,  we  see  that  the  invagination 
was  really  of  the  ileum  into  the  colon,  although  a  small  portion  of 
the  ileum  next  to  the  valve  had  not  been  inverted,  and  constituted 
a  little  of  the  exterior  of  the  mass. 

Intussusception,  irreducible  and  fatal,  may,  however,  occur  in 
the  small  intestines  in  infancy  as  well  as  childhood.  Probably 
the  displacement  is  at  first  of  the  simple  variety,  but,  continuing 
and  increasing  in  extent,  its  return  becomes  impossible.  The  posi- 
tive statement  of  so  great  an  authority  as  M.  Pilliet,  that  irredu- 
cible intussusception  does  not  occur  in  the  small  intestines,  justifies 
the  publication  of  the  following  cases,  which  establish  the  fact 
that  there  are  instances,  though  not  frequent,  in  which  the  disease 
does  have  this  location. 

Case  1. — Male.  This  patient's  health  had  been  uniformly  good,  and 
uothing  unusual  was  observed  in  his  conditiou  till  the  age  of  four  and 
a  half  mouths,  when  he  became  restless  as  if  in  almost  constant  pain, 


INTUSSUSCEPTION    IN    THE    SMALL    INTESTINES.        657 

with  occasional  exacerbations.     Castor  oil  was  prescribed,  wliich  ope- 
rated freely,  and  then  the  following  mixture: — 

R.  Magnos.  calcinut.  ^j  ; 

Tiiict.  opii  canipliorat.  3ij  ; 
Tinct.  !iss;il(H!t.  .^ss  ; 
A(i.  aiiisi  5J.     Misce. 
Dose,  ten  to  twenty  drops,  repeated  according  to  the  pain. 

These  remedies  failed  to  give  relief,  as  did  also  chloroform  given 
in  doses  of  two  drops.  After  two  or  tliree  days,  another  set  of  symp- 
toms arose,  those  characteristic  of  pneumonitis,  namely,  hurried  resjji- 
ration,  accelerated  pulse,  short,  suppressed  cough,  and  exj)iratory  moan. 
He  was  treated  with  the  oiled-silk  jacket,  and  mild  counter-irritation, 
and  took  an  expectorant  mixture  containing  carbonate  of  ammonia.  In 
a  few  days  the  pulmonary  disease  was  evidentl}'  subsiding,  but  the  pain 
in  the  abdomen,  with  occasional  exacerbations,  continued.  His  counte- 
nance was  pallid,  and  bore  an  expression  of  suffering.  There  was  no 
distension  or  tenderness  of  abdomen,  and  no  abdominal  tumor.  He 
took  little  nutriment,  and  seldom  vomited.  In  the  last  part  of  his  sick- 
ness the  dejections  were  scanty,  and  the  last  three  days  his  stools  con- 
sisted mainly  of  mucus  and  a  little  blood.  The  pain  seemed  to  be  grow- 
ing less,  when  he  was  seized  with  convulsions,  and  died  tlie  same  day, 
precisely  two  weeks  from  the  commencement  of  his  sickness. 

Secfio  Cadaver. —  Head  not  examined;  body  slightly  emaciated; 
mucous  membrane  of  trachea  and  bronchial  tubes  vascular  ;  posterior 
portion  of  the  lower  lobe  of  each  lung  solid,  of  a  greater  specific  gravity 
than  water,  and  allowing  only  partial  inflation  ;  it  was  in  the  second 
stage  of  pneumonitis.  Stomach,  duodenum,  jejunum,  healthy.  In  the 
upper  part  of  the  ileum  was  an  intussusception  two-thirds  of  an  inch 
long,  presenting  no  trace  of  inflammation,  either  within  or  around  it, 
and  its  vascularity,  when  it  was  examined  externally,  did  not  seem 
notably  increased.  Above  the  intussusception  the  intestine  was  empty  ; 
below  it,  and  chiefly  in  the  small  intestine,  was  a  dark-colored  substance 
evidently  blood,  and  giving  in  a  few  hours  the  offensive  odor  of  decaying 
animal  matter.  There  was  a  passage  through  the  intussusception,  at 
least  two  or  three  lines  in  diameter,  as  shown  by  a  probe.  The  intussus- 
ception sustained  the  weight  of  sixteen  inches  of  the  intestine,  and  it 
would  apparently  have  sustained  considerably  more.  The  remaining 
organs  were  healthy. 

Case  II. — F.  S.,  a  female  infant,  four  months  old,  was  treated  at  the 
New  York  Infant  Asylum  in  June  and  July,  1865,  for  entero-colitis,  the 
usual  epidemic  of  the  summer  season.  The  following  records  show  the 
state  of  the  bowels  immediately  before  her  death  : — • 

June  29th.  Has  five  or  six  stools  daily.  30th.  Two  stools  in  twenty- 
four  hours.  July  1st.  Had  two  stools  since  the  last  record ;  no  vomit- 
ing. 3d.  Four  dejections  in  twent^^-four  hours.  4th.  The  diarrhoea 
continues  as  before ;  dejections  about  four  daily.  On  the  6th  of  July 
she  died. 

Her  pulse  during  the  time  in  which  these  records  were  taken  gene- 
rally numbered  about  128  per  minute.  She  was  much  emaciated,  and 
the  day  before  death  she  frequently  struck  her  head  with  the  hand. 
The  medicines  employed  were  mainly  alkalies  and  astringents. 

Sectio  Cadaver. — Parietal  bones  united  ;  serous  eflfusion  lying  over 
the  convolutions  of  the  brain,  under  the  arachnoid ;  occipital  bone 
42 


658 


INTUSSUSCEPTION, 


depressed ;  coininencing  at  a  point  about  two  feet  below  the  stomach 
were  four  intussusceptions  two  or  three  inches  from  each  otlier.  The 
Invaginated  masses  were  from  one  to  one  and  a  half  inch  in  length,  and 
three  of  them  were  found  to  be  very  vascular  in  their  interior.     Above, 


between,  and  immediately  below^  the  intussusceptions  the  intestine  was 
healthy.  One  of  the  invaginations  was  tested  by  weight,  and  was  found 
to  sustain  one  and  h  half  foot  of  intestine,  and  would  have  sustained 
more.  Water  poured  above  these  intussusceptions  escaped  through 
them  very  slowly ;  no  fibrinous  exudation  ;  descending  colon  vascular 
and  thickened,  and  solitary  glands  enlarged. 

The  irreducible  character  of  the  intussusceptions  in  the  above 
cases  was  shown  by  the  fact  that  they  sustained  weights  which 
doubtless  produced  greater  traction  than  that  exerted  by  the  in- 
testine in  its  normal  action.  That  the  displacement  existed  prior 
to  the  moment  of  death  was  shown  not  only  by  the  symptoms  in 
one  case,  but  by  the  anatomical  changes  which  had  occurred  in 
both.  In  one  the  capillaries  of  the  incarcerated  mass  were  rup- 
tured during  the  last  days  of  life,  so  as  to  produce  sanguineous 
stools ;  while  in  the  other  there  was  intense  congestion  of  the 
confined  membrane,  while  that  adjacent  was  healthy. 

In  both  cases  there  was  less  violence  of  symptoms,  and  the 
disease  seemed  to  come  on  more  gradually  than  in  the  first  and 
second  cases  of  our  table,  in  which  the  portion  of  intestine  which 
was  engaged  was  the  same,  but  the  patients  older.  In  fact,  the 
imprisoned  intestine  was  pervious,  so  as  to  allow  the  passage  of 
food  in  one  case  through  the  entire  sickness,  and  in  the  other  till 
near  the  close  of  life.     At   the  post-mortem  examinations,  the 


INTUSSUSCEPTION    IN    LARGE    INTESTINES.  659 

intestines  were  found  cm})ty  above  the  intussusceptions,  and  water 
slowly  passed  through  them. 

It  is  my  opinion  that  intussusception  of  the  small  intestines  in 
the  infant,  commencing  as  the  simple  form,  may  become  irredu- 
cible, and  yet  remaining  pervious  continue  for  weeks  without 
giving  rise  to  those  severe  symptoms  which  ordinarily  characterize 
this  disease.  The  following  case,  which  I  have  not  thought  best 
to  include  in  my  table,  was  apparently  an  example  of  this : — 

Case — Male  child,  died  at  the  age  of  nineteen  months,  the  last  eleven 
of  which  he  was  under  observation.  The  mother  states  that  he  had 
never  been  well  since  the  age  of  one  month,  and  that  there  had  been  little 
variation  in  the  symptoms  of  his  disease.  During  the  period  in  which 
he  was  under  observation,  he  was  ordinarily  fretful,  and  frequently 
seemed  to  be  in  considerable  pain.  His  stomach  through  this  whole 
time  was  so  irritable,  that  he  rarely  toolv  more  than  three  or  four  spoon- 
fuls of  nutriment  without  vomiting.  There  was  usually  more  or  less 
diarrhoea,  but  no  tenderness  or  distension  of  abdomen.  He  became 
slowly  but  gradually  more  emaciated,  and  finally  died  in  a  state  of 
extreme  emaciation  and  exhaustion.  He  had  no  convulsions,  and  was 
conscious  to  the  last. 

Sectio  Cadaver. — Brain  not  examined;  lungs  healthy,  except  a  cir- 
cumscribed portion,  which  was  inflamed  at  the  summit  of  the  right  lung; 
liver  small  and  almost  destitute  of  oily  matter,  as  shown  by  the  micro- 
scope. In  the  jejunum,  about  two  feet  below  the  stomach,  was  an  intus- 
susception two  inches  long,  the  intestine  forming  which  seemed  to  have 
undergone  no  structural  change.  Above  the  intussusception  the  intestine 
was  of  small  calibre,  and  entirely  empty  and  pale ;  below  the  intussus- 
ception the  intestine  was  somewhat  larger  than  above,  but  it  seemed 
quite  healthy.  The  invagination  was  sufficiently  pervious  to  allow  water 
to  pass  through  it,  and  it  readily  sustained  the  weight  of  two  feet  of 
intestine.  From  eight  to  ten  inches  below  this  intussusception  there 
was  another,  which  was  immediately  drawn  out  the  moment  the  intestine 
was  disturbed.     The  other  abdominal  viscera  were  healthy. 

There  is  uncertainty  as  to  the  duration  of  intussusception  in  the 
above  case.  Though  the  symptoms  indicated  that  it  existed  a 
considerable  time  prior  to  death,  yet  there  was  no  strangulation, 
nor  indeed  any  appreciable  anatomical  alteration  in  the  coats  of 
the  intestine.  The  fact  that  the  invaginated  mass  sustained  two 
feet  of  intestine,  and  required  considerable  traction  for  its  reduc- 
tion, transfers  the  case  from  the  simple  to  the  irreducible  variety. 

Intussusception  in  Large  Intestines. 

In  most  cases  of  irreducible  intussusception  in  infancy  and 
childhood,  the  ileum  is  invaginated  in  the  colon,  or  the  first  part 
of  the  colon  is  invaginated  in  the  part  succeeding  it.  By  referring 
to  the  table  (Appendix)  it  will  be  seen  that  intussusception  not 
unfrequently  begins  in  the  prolapse  of  the  ileum  through  the  ileo- 


660  INTUSSUSCEPTION. 

coecal  valve,  in  the  same  way  that  prolapse  of  the  rectum  occurs 
through  the  sphincter  ani.  If  death  take  place  early,  as  in  Case  6, 
only  a  small  portion  of  the  ileum  may  have  passed  the  valve.  If 
the  case  is  protracted,  the  tenesmus  brings  down  more  and  more 
of  the  ileum,  with  its  accompanying  mesentery.  The  constriction 
of  the  valve,  which  acts  as  a  ligature,  soon  prevents  the  further 
descent  of  the  ileum ;  and,  the  tenesmus  continuing,  the  next  step 
in  the  morbid  process  is  the  inversion  of  the  caput  coli,  which  is 
drawn  into  the  colon  by  the  descending  mass,  and,  unless  the  case 
terminate  by  sloughing  or  death,  the  ascending  and  transverse 
portions  of  the  colon  are  successively  invaginated.  The  records 
show  that  intussusception  occurs  as  above  stated  in  a  large  pro- 
portion of  cases.  In  one  case,  No.  18,  the  intussusception  began 
a  few  inches  above  the  valve,  so  that  the  ileum  constituted  a  small 
portion  of  the  exterior  of  the  mass.  Occasionally  the  coecum  is 
the  part  primarily  inverted  and  invaginated,  and,  descending  along 
the  colon,  it  draws  after  it  the  ileum,  which  sustains  its  natural 
relation  to  the  ileo-cascal  valve.  When  this  occurs  the  ccecum  is 
found  at  the  lower  end  of  the  mass,  and  two  orifices  are  observed, 
one  leading  through  the  valve,  and  the  other  into  the  appendix 
vermiformis.  In  Cases  14,  17,  20,  21,  26,  and  37  (Appendix),  the 
intussusception  evidently  commenced  with  the  caput  coli.  These 
two  forms  of  invagination — that  in  which  the  ileum,  passing 
through  the  ileo-ccecal  valve,  successively  inverts  and  draws  after 
it  the  caput  coli  and  the  divisions  of  the  colon ;  and  that  in  which 
the  caput  coli  is  primarily  invaginated,  and  descending  along  the 
large  intestines,  inverts  the  latter,  and  draws  after  it  the  ileum — 
constitute  the  vast  majority  of  cases  of  this  disease  in  infancy  and 
childhood.  In  Cases  5  to  42,  the  parts  invaginated  were  the  ileum 
or  caput  coli,  or  both,  generally  with  a  portion  of  the  colon.  In 
one  case,  44,  the  intussusception  was  in  the  transverse  colon;  in 
one,  43,  in  the  descending  portion;  and  in  one,  45,  in  the  lower 
portion  of  the  descending  colon  and  in  the  rectum.  Rarely  (24, 
35,  and  37)  double  invagination  occurs.  The  first  invagination 
becomes  arrested  in  its  progress,  and  by  the  strong  expulsive  eftbrt 
of  the  patient,  descends  into  the  portion  of  intestine  below,  form- 
ing a  mass  of  great  thickness,  and  necessarily  fatal.  In  exceptional 
cases  there  is  so  little  constriction  of  the  invasfinated  intestine  that 
it  remains  pervious,  though  with  diminished  calibre.  In  these 
cases  life  may  be  protracted  for  weeks  or  even  months,  the  evacu- 
ations being  sufiicient  for  the  Avants  of  the  system.  Death  occurs, 
finally,  in  a  state  of  exhaustion.     Case  9  was  a  notable  example  of 


INTUSSUSCEPTION    IN    LARGE    INTESTINES.  661 

this.      This  child,  four   months   old,  lived   six  weeks   after   the 
symptoms  of  invagination  commenced,  and  seventeen  days  "with  a 
portion  of  the  bowel  protruding  from  the  anus."     It  was  found  at 
the  post-mortem  examination  that  part  of  the  ileum  had  descended 
through  the  entire  colon,  and  had  remained  pervious.     Case  37 
was  another  example  of  the  same.     It  is  not  known  at  what  time 
the  invagination  began  in  this  case,  though  there  were  symptoms 
of  it  for  seven  months  before  death.     During  the  last  six  weeks  of 
life,  the  invaginatcd  intestine  protruded  frequently  from  the  anus, 
and  was  replaced  by  the  mother.     In  this  case  "  the  ccecum  was 
inverted,  and  descended  through  the  colon  to  the  lower  portion  of 
the  rectum,  carrying  with  it  the  ileum  and  the  entire  colon,  except 
the  last  ten  or  twelve  inches."    In  Case  21  the  symptoms  indicated 
a  continuance  of  the  disease  for  three,  if  not  eight,  months.    As  the 
intestine  becomes  invaginated,  its  mesentery  or  meso-colon  is  also 
invaginated,  and,  with  rare  exceptions,  its  veins  compressed.     The 
pathological  state  of  the  incarcerated  mass  soon  becomes  that  of 
intense  congestion.     In  infants,  usually  in  a  few  hours,  so  great  is 
the  distension  of  the  capillaries  that  they  give  way,  blood  escapes 
into  the  intestine,  and  passes  from  the  bowels  in  scanty  motions. 
On  examining  the  invaginated  intestine  after  death,  if  gangrene 
has  not  occurred,  it  is  found  of  a  uniform  intense  red  color,  some- 
times resembling  to  the  naked  eye  a  long  and  firm  clot  of  blood. 
In  those  who  die  early  there  are  no  traces  of  inflammation,  but  in 
more  protracted  cases  the  attrition  between  the  serous  surfaces 
excites  local  peritonitis.     In  none  of  the  fifty-two  cases  in  which 
post-mortem  examinations  were  made,  did  the  inflammation  extend 
more  than  a  few  lines   beyond  the  invagination.      Usually  the 
intestine  forming  the  exterior  of  the  invaginated  mass  is  much 
drawn  together  or  puckered.     In  the  case  treated  by  myself,  36, 
the  entire  large  intestine  which  formed  the  exterior  was  compressed 
within  a  space  of  six  inches  or  less,  since  about  twelve  inches  of 
the  ileum  doubled  on  itself,  passed  through  the  entire  colon  so  as 
to  protrude  from  the  anus,  the  only  part  of  the  large  intestine 
inverted  being  the  caput  coli.     In  Case  18,  six  or  seven  inches  of 
the  ileum,  which  formed  a  portion  of  the  exterior  of  the  mass,  were 
compressed  within  the  space  of  one  inch. 

The  abdomen,  at  first  of  natural  fulness  and  soft,  usually  becomes 
more  and  more  distended  till  the  close  of  life ;  but  in  cases  of  much 
vomiting  the  distension  is  moderate.  This  fulness  is  due  to  gas 
and  ffecal  accumulation  above  the  invagination.     The  portion  of 


662  INTUSSUSCEPTION.' 

intestine  below  it  is  generally  empty,  unless  it  contain  a  little 
blood,  and  is  sometimes  contracted. 

There  are  few  morbid  changes  in  intussusception  beside  those 
pertaining  to  the  intestine.  Sir  James  Y.  Simpson  saw  Case  51, 
and  remarked,  before  the  medical  society  at  which  the  specimen 
was  exhibited,  that  it  appeared  to  him,  from  the  distended  state  of 
the  cutaneous  veins,  that  the  ascending  vena  cava  was  compressed 
by  cicatrization  at  the  point  where  the  intestine  had  sloughed.  In 
Case  40,  there  was  probably  compression  of  the  left  iliac  artery; 
for  two  days  after  the  expulsion  of  the  coecum  and  a  part  of  the 
colon  which  had  sloughed,  pulsation  ceased  in  the  left  leg,  and  all 
that  part  below  the  patella  became  gangrenous.  The  patient 
gradually  recovered  with  the  loss  of  the  leg.  The  only  probable 
explanation  of  such  cases  is  that  the  bloodvessels  are  compressed 
by  the  cicatrization  and  contraction  which  follow  the  sloughing 
of  the  intestine,  such  as  occurred  in  Case  48.  This  child,  on  the 
eighth  day  of  his  sickness,  lost  by  stool  fifteen  to  eighteen  inches 
of  the  ileum,  after  which  he  rapidly  recovered.  Twelve  weeks 
later  he  was  seized  with  typhus  fever,  which  proved  fatal  in  two 
weeks.  The  records  state,  "The  traces  of  the  diseased  bowels 
were  visible  by  a  considerable  puckering  and  contraction  where  the 
slough  had  taken  place  and  the  parts  united."  This  case  shows 
that  the  supposition  that  cicatrization  in  rare  instances  arrests  the 
circulation  and  gives  rise  to  gangrene  receives  confirmation  from 
post-mortem  inspection.  In  Case  40,  although  the  coecum  and  a 
part  of  the  colon  contiguous  were  discharged,  the  seat  of  the 
invagination  was  probably  the  descending  colon,  if  not  lower  still, 
so  as  to  correspond  with  the  common  or  perhaps  internal  iliac 
artery. 

Symptoms. — The  symptoms  vary  according  to  the  age  of  the 
patient  and  the  degree  of  strangulation  in  the  part  invaginated. 
Pain  in  the  abdomen,  usually  paroxysmal,  is  among  the  first,  and 
is  one  of  the  most  conspicuous  symptoms.  It  is  often  severe, 
resembling  the  pain  of  hernia,  and  abating  only  with  the  failing 
strength  of  the  child.  After  the  first  few  days,  if  inflammation 
arises,  the  pain  is  continuous,  though  more  severe  in  paroxysms. 
At  first  pressure  upon  the  abdomen  is  tolerated,  but  afterwards 
there  is  tenderness.  This  is  also  due  to  the  inflammation,  which 
occurs  in  and  around  the  invaginated  mass.  It  is  therefore  con- 
fined to  the  part  of  the  abdomen  which  corresponds  with  the 
invagination.  At  this  point  the  abdomen  is  more  full  than  else- 
where, and  not  unfrequently  the  physician  can  feel  the  invaginated 


SYMPTOMS,  663 

mass  and  detect  its  exact  location.  Sometimes,  at  an  early  period 
as  well  as  late,  cerebral  symptoms  occur,  as  in  Case  6,  wliicli  termi- 
nated in  convulsions  on  the  second  day.  Convulsions  are,  however, 
comparatively  rare,  and  the  mind  is  generally  clear  till  the  last 
moment.  In  infants  the  countenance,  in  the  intervals  of  pain,  in 
the  first  stages  of  the  complaint,  is  often  placid  and  not  indicative 
of  any  serious  disease,  but  in  older  patients  constant  and  severe 
local  symptoms,  referable  to  the  intussiisception,  commence  early. 
At  an  advanced  period,  whatever  the  age,  the  countenance  becomes 
anxious  and  haggard,  the  eyes  hollow  or  sunken,  the  body  loses  its 
plumpness,  and,  if  the  case  is  protracted,  becomes  emaciated. 

Vomiting  is  rarely  absent ;  in  thirty-nine  out  of  forty-seven 
cases  it  is  stated  to  have  been  present ;  in  seven  cases  there  is  no 
record  of  this  symptom,  while  it  is  recorded  absent  in  only  one 
case.  This  is  Case  52,  the  record  of  which  is  very  meagre,  and 
death  occurred  the  second  day.  The  vomiting  becomes  stercora- 
ceous  in  a  few  days,  and  it  ordinarily  continues  with  greater  or 
less  frequency  till  the  period  of  collapse.  It  relieves  partially  the 
distension. 

The  appetite  is  impaired  and  often  entirely  lost.  Infants  at  the 
breast  commonly  nurse,  however,  for  several  days,  probably  from 
thirst  rather  than  hunger. 

There  is  commonly  one  natural  evacuation  from  the  bowels  after 
the  intussusception  commences,  and  then  obstinate  constipation 
succeeds.  This  evacuation  consists  of  the  excrementitious  matter 
below  the  invagination.  In  children  under  the  age  of  one  year, 
scanty  motions  of  blood  mixed  with  mucus  begin  to  occur  in  a  few 
hours.  In  twenty-seven  children  under  this  age  I  find  that  twenty- 
four  had  such  evacuations,  occurring  in  most  of  them  several  times 
in  the  course  of  the  day ;  in  two  of  the  twenty-seven  there  is  no 
record  of  this  symptom,  but  in  the  remaining  case  it  is  stated  to 
have  been  absent.  Scanty  evacuations  of  blood  unmixed  with  fsecal 
matter  have  been  considered  pathognomonic  of  intussusception  in 
the  infant,  and  we  see  the  ground  for  such  belief ;  but  in  excep- 
tional instances  the  invaginated  mass  is  partly  pervious,  and  al- 
though the  dejections  may  contain  blood  they  are  also  excremen- 
titious. In  our  collection  of  cases  are  three  examples  of  this  in 
infants  under  the  age  of  one  year.  One  has  already  been  referred 
to.  In  this  case  there  was  the  rare  anomaly  of  so  large  an  opening 
through  the  ileo-ccecal  valve,  as  to  allow  not  only  prolapse  and  de- 
scent of  the  ileum  through  the  entire  colon,  so  as  to  protrude  six 
inches  from  the  anus,  but  also  feecal  passages  through  it  daily. 


664:  INTUSSUSCEPTION. 

In  children  above  the  age  of  one  year,  the  capillaries  of  the 
invaginated  intestine  are  not  so  frequently  ruptured  as  under  this 
age,  and  sanguineous  evacuations  are  therefore  less  common.  I 
have  records  of  nineteen  cases  between  the  ages  of  one  year  and 
twelve,  in  only  six  of  which  is  it  stated  that  there  were  bloody 
motions,  and  in  these  the  blood  was  not  passed  frequently,  nor  even 
in  some  cases  daily,  as  in  infants,  nor  in  so  pure  a  state,  unless  in 
Cases  9  and  11,  the  records  of  which  are  not  explicit  on  this  point. 
Two  of  these  six  patients  passed  moderate  bloody  evacuations  after 
protracted  periods  of  constipation,  one  had  faecal  discharges  with 
the  blood  through  the  entire  sickness,  and  in  one  blood  was  passed 
at  first  but  finally  the  stools  were  entirely  excrenientitious. 

In  those  above  the  age  of  one  year,  there  was  for  the  most  'part 
obstinate  constipation,  no  dejections,  whether  bloody  or  fsecal, 
occurring  for  several  days,  but  there  were  a  few  exceptions.  In 
Cases  7,  21,  and  37,  the  bowels  were  relaxed.  The  ileum,  in  these 
three  cases,  had  descended  through  the  entire  colon,  or  the  larger 
part  of  the  colon,  and  being  pervious,  the  faeces  escaped  from  the  anus 
without  detention  in  the  large  intestine,  or  with  detention  only  in 
its  lower  portions,  and  were  therefore  liquid. 

Tenesmus  is  another  symptom.  It  is  not  always  present,  but 
in  a  large  proportion  of  cases,  even  when  the  invagination  is  in 
the  upper  part  of  the  large  intestine,  it  is  a  frequent  and  distress- 
ing symptom.  It  often  does  not  commence  till  there  is  a  consider- 
able amount  of  displacement,  and  it  ceases  when  the  strength  is 
much  reduced. 

The  temperature  of  the  surface  is  normal  in  the  commencement 
of  intussusception ;  but  finally,  as  febrile  reaction  comes  on  symp- 
tomatic of  the  inflammation,  it  rises  and  continues  above  the 
healthy  standard  till  the  intestine  sloughs,  or  till  the  stage  of 
collapse  occurs  which  ushers  in  death.  The  pulse,  especially  in 
the  infant,  is  tranquil  at  first,  but,  whatever  the  age,  it  soon 
becomes  accelerated  from  the  paroxysms  of  pain,  and  subsequently 
from  the  inflammation  which  occurs  in  the  invaginated  mass. 
There  is  no  disturbance  of  respiration,  except  that  it  is  somewhat 
hurried  from  the  fever,  and  from  the  pain  felt  in  advanced  cases  on 
full  inspiration. 

It  will  be  seen  that  the  symptoms  vary  in  certain  particulars, 
under  the  age  of  one  year,  from  those  occurring  over  that  age,  but 
differences  in  the  symptoms  depend  more  on  the  degree  of  invagi- 
nation and  constriction,  than  on  the  age  and  exact  location  of  the 
disease. 


DIAGNOSIS  —  DURATION.  665 

Diagnosis. — The  diagnosis  of  intussusception  is  not,  in  general, 
(liiHcult,  except  at  its  commencement.  "When  the  inversion  has 
reached  that  degree  at  which  ohstruction  occurs,  the  symptoms 
are,  in  most  cases,  such  tliat  the  diseasp  can  be  readily  diagnosti- 
cated. In  the  cases  the  records  of  which  I  have  collected,  a 
correct  diagnosis  was,  Avith  few  exceptions,  made,  and  at  an  early 
period.  In  the  infant,  the  disease  for  which  intussusception  is 
most  frequently  mistaken  is  dysentery,  on  account  of  the  tenesmus 
and  the  muco-sanguineous  stools.  In  certain  of  the  reported  cases 
this  mistake  was  not  rectified  until  it  was  ascertained  that  purga- 
tives produced  no  frecal  evacuations. 

The  symptoms  which  are  commonly  present,  and  which  indicate 
the  nature  of  the  disease,  are  obstinate  constipation,  vomiting, 
paroxysmal  pain  referred  to  the  seat  of  the  disease,  and  tenesmus. 
In  the  infant,  also,  scanty  evacuations  from  the  bowels  of  mucus 
and  blood,  or  of  pure  blood,  is  an  important  diagnostic  sign.  It 
should  be  borne  in  mind,  however,  that  in  exceptional  cases  the 
displaced  bowel  may  remain  pervious,  and  the  symptoms  which 
possess  so  great  diagnostic  value  therefore  be  absent.  There  may 
be  no  vomiting  or  tenesmus,  and  there  may  even  be  diarrhoea  in 
place  of  constipation.  As  an  aid  to  diagnosis,  it  should  be  stated 
that  whatever  the  age  of  the  child  afiected  with  intussusception, 
clysters  are  commonly  administered  with  difficulty,  and  are  quickly 
and  forcibly  returned,  on  account  of  the  resistance  opposed  by  the 
invaginated  mass.  The  seat  and  even  extent  of  displacement  can 
be  ascertained  in  a  large  proportion  of  cases  by  a  digital  examina- 
tion of  the  abdominal  walls.  The  tumor  can  be  felt  hard,  elongated, 
and  tender  on  pressure.  If  the  invagination  be  in  the  lower  part 
of  the  large  intestine,  it  can  sometimes  be  discovered  by  an  exami- 
nation per  rectum. 

Duration. — In  the  following  table,  the  duration  of  the  intus- 
susception in  forty-nine  cases  is  given,  as  nearly  as  it  can  be 
ascertained  from  the  records: — 

1  died  the  8th  day. 
1     "      "10th    " 
1     "      "14th    " 
1  lived  nearly  a  week. 
1     "     (Case  9)  6  weeks, 
3,  time  of  death  not  given. 
7  recovered. 
1  lived  over  a  week. 

In  the  three  remaining  cases,  4,  21,  and  37,  the  exact  duration 
is  not  certain ;  but  it  was  probably  far  beyond  the  usual  period. 


2  died  the  1st  day, 

G     " 

"   2d     " 

14     " 

"   3d     " 

2     " 

"   4th  " 

5     " 

"   5th  " 

2     " 

"   6th   " 

2     " 

"   7th  " 

666  INTUSSUSCEPTION. 

The  second  of  these  (21),  a  girl  of  six  years,  having  eaten  raw 
carrots,  was  seized  with  pain  in  the  abdomen,  which  lasted  eight 
months,  when  she  died.  During  the  last  three  months  she  passed 
mucus  and  blood.  In  this  case  the  coecum  had  descended  to  the 
anus,  drawing  with  it  the  ileum,  which  remained  pervious.  The 
symptoms  indicated  the  continuance  of  the  invagination  for  three 
months  if  not  eight.  In  the  third  case  (37),  the  child  complained 
of  pain  in  the  abdomen  for  many  months,  and  occasionally  vomited. 
During  the  last  six  weeks  of  his  life,  all  the  phenomena  of  invagi- 
nation were  present.  The  pathological  condition  of  the  intestine 
found  after  death  was  essentially  the  same  in  both  cases. 

In  "W^est's  Treatise  on  Diseases  of  Children  (fifth  edition,  1866, 
page  504),  it  is  stated  that  death  in  this  complaint  always  occurs 
within  a  week.  The  above  statistics,  however,  show  that  there 
are  exceptions  to  this  statement,  although  a  large  majority  do  die 
within  the  first  seven  days.  In  thirty-three  of  the  cases  embraced 
in  my  statistics  death  occurred  within  the  first  week,  and  in  no 
fatal  case  in  which  strangulation  was  complete  was  life  prolonged 
beyond  the  eighth  day.  In  these  cases  of  complete  strangulation 
the  average  duration  was  3.7  days,  and  the  largest  number  of 
deaths  occurred  on  the  third  day.  Death  on  the  first  day  is  rare, 
but  it  occurred  in  two  instances.  When  so  early  it  is  often,  if  not 
generall}',  through  convulsions  and  coma. 

Prognosis. — Intussusception  is  in  its  nature  so  grave  an  accident 
that  the  physician  called  to  a  case  should  always  expect  and  pre- 
dict a  fatal  result.  A  favorable  issue  is  only  through  an  unusual 
combination  of  circumstances.  But,  while  death  is  the  common 
result,  there  are  three  difterent  modes  of  termination  in  which  life 
is  preserved.  First,  the  reduction  of  the  incarcerated  intestine, 
with  immediate  relief.  There  can  be  no  doubt  that  it  is  possible 
for  intussusception,  when  recent,  to  be  reduced  by  the  unaided 
action  of  the  bowels,  in  the  same  way  as  the  common,  simple  in- 
tussusception in  the  jejunum  and  ileum,  or  as  hernia  is  reduced, 
through  the  vermicular  action  of  the  intestines.  For  sometimes, 
as  in  Case  6,  there  previously  have  been  the  same  symptoms  as 
those  which  accompanied  the  fatal  attack,  and  which  subsiding, 
the  patient  remained  for  a  time  in  perfect  health.  This  termina- 
tion is  probably  rare,  if  the  symptoms  are  sufiiciently  marked  to 
necessitate  treatment.  A  considerable  number  of  observations 
also  establish  the  fact  that  intussusception  may  occasionally  be 
cured  by  early  and  well-applied  treatment.  The  physician  may 
succeed  in  reducing  the  displaced  intestine,  even  if  the  intussus- 


PROGNOSIS.  667 

ception  is  in  the  upper  part  of  tlie  colon.  Relief  in  these  cases, 
wlictlier  by  the  unaided  movements  of  the  intestine  or  by  the  phy- 
sician's art,  is  obviously  immediate. 

A  second  mode  of  favorable  termination  is  alluded  to  by  certain 
foreign  writers.  The  intussusception  continues  for  a  considerable 
period  -with  the  characteristic  symptoms,  and  then,  as  Bouchut 
expresses  it,  "the  vomitings  gradually  cease,  the  intestinal  hemor- 
rhage disappears,  the  strength  returns,  and  the  health  becomes 
restored  without  the  expulsion  of  fragments  of  the  intestine." 
"What  changes  the  displaced  intestine  undergoes  in  these  protracted 
cases,  which  gradually  recover  without  sloughing,  have  not  been 
clearly  ascertained,  although  they  have  been  the  subject  of  con- 
jecture. According  to  Rilliet,  a  large  proportion  of  favorable  cases 
terminate  in  this  manner.  It  does  not  appear,  however,  from  the 
statistics  which  I  have  collected,  that  this  is  a  common  mode  of 
recovery.  The  clinical  history  of  intussusception  establishes  the 
fact  that  in  a  large  majority  of  protracted  cases  there  is  either  death, 
or  the  third  mode  of  favorable  termination,  namely,  by  sloughing. 

Infants  with  intussusception  other  than  the  simple  form,  which 
was  described  at  the  beginning  of  this  paper,  commonly  die.  The 
reason  of  this  is  obvious  when  we  consider  that,  in  a  few  hours  after 
the  invagination  begins,  the  imprisoned  mass,  with  now  and  then 
an  exception,  becomes  so  congested  that  its  capillaries  give  way, 
and  its  reduction  is  impossible  by  any  appliance  of  medical  art. 
"We  cannot  reasonably  expect  recovery  except  through  sloughing 
and  the  expulsion  of  the  intestine ;  and  few  infants,  have  the  re- 
quisite strength  for  so  tedious  and  exhaustive  a  process.  The 
youngest  child  that  recovered  in  this  way,  so  far  as  I  can  ascertain, 
was  one  reported  by  M.  Marage,  namely,  an  infant  thirteen  months 
old.  With  the  exception  of  this  case,  the  youngest  was  (42)  a  boy, 
five  years  of  age.  The  older  the  child,  the  greater,  of  course,  the 
power  of  endurance,  and  the  better  the  prospect  of  recovery.  In 
our  collection  are  the  records  of  seven  cases  which  resulted  favor- 
ably by  sloughing.  These  children  were  of  the  ages  of  five,  six,  six, 
nine,  eleven,  twelve,  and  twelve  years.  The  separation  of  the 
invaginated  mass  occurred  in  six  of  these  between  the  sixth  and 
twelfth  days,  with  an  average  of  nine  and  a  half  days,  the  time  not 
being  given  in  one  case.  If,  then,  the  patient  can  be  carried 
through  the  first  week  without  too  much  exhaustion,  we  may  each 
day  look  for  the  discharge  of  the  slough,  the  reopening  of  the  bowels, 
and  ultimate  recovery. 

In  those  rare  cases  in  which  there  are  daily  fsecal  dejections, 


668  INTUSSUSCEPTION. 

recovery  is  still  improbable.  At  an  early  period  reduction  is  no 
doubt  more  easy  in  these  cases  than  when  there  is  strangulation, 
but  from  the  absence  of  strangulation  the  intussusception  usually 
becomes  greater,  and  sloughing  is  less  likely  to  occur;  so  that, 
although  the  case  is  more  protracted  and  the  symptoms  less  severe, 
death  is  the  ordinary  result. 

Mode  of  Death. — In  a  large  majority  of  cases  death  is  through 
asthenia.  There  may  be  convulsive  movements,  more  or  less 
marked,  but  the  prevailing  characteristic  as  death  approaches  is 
extreme  exhaustion.  In  exceptional  cases  the  life  of  the  sufferer 
is  cut  short  by  convulsions  before  the  stage  of  exhaustion  is  reached, 
as  in  Cases  2  and  6. 

Treatment. — It  is  unfortunate,  in  cases  of  intussusception,  that 
the  time  in  which  treatment  can  be  of  most  service  is  apt  to  pass 
by,  before  the  true  condition  of  the  intestine  is  detected.  Invagi- 
nation being  comparatively  rare,  the  patient  is  generally  on  the 
first  day  treated  for  colic  or  dysentery  or  some  other  common  affec- 
tion of  the  bowels ;  and  it  is  often  not  till  the  second  day,  when 
the  intestine  has  become  incarcerated,  that  the  physician  accu- 
rately diagnosticates  the  disease.  The  purgative  medicines  usually 
given  in  the  commencement  injure  the  patient.  In  fact,  both 
reason  and  experience  teach  us  the  impropriety  of  such  treatment 
in  this  complaint.  Cathartic  remedies  act  as  avis  d  tergo,  and  may 
cause  a  still  further  descent  of  the  inverted  intestine.  Yet  such 
powerful  agents  of  this  class  as  quicksilver  have  been  employed. 
It  was  administered  in  two  doses  of  one  ounce  each  in  one  of  the 
cases  embraced  in  my  statistics,  but  none  of  the  mineral  passed  the 
bowels.  At  the  post-mortem  examination  a  considerable  part  of 
it  was  found  in  small  globules,  coated  with  a  black  layer  consist- 
ing of  the  sulphuret  or  black  oxide  of  mercury  in  the  intestine 
above  the  intussusception.  It  need  not  be  added  that  the  case  was 
speedily  fatal. 

The  proper  treatment  of  intussusception  consists  in  attempts  to 
reduce  the  displacement  by  pressure  from  below.  This  pressure 
may  be  applied  either  by  liquid  injections  into  the  rectum,  or, 
which  is  far  preferable,  inflation  of  the  lower  intestine  by  air  or 
gas.  If  reduction  is  not  effected  after  sufiicient  trial,  the  indica- 
tion is  to  sustain  the  strength  of  the  patient  and  give  palliative 
remedies  in  the  hope  that  recovery  may  take  place  through  the 
process  of  sloughing  and  adhesive  inflammation.  If  we  may  judge 
from  the  remarks  of  physicians  who  have  reported  cases,  and  by 
discussions  in  societies  in  which  specimens  have  been  presented, 


TREATMENT,  669 

this  mode  of  treatment  is  accepted  by  the  profession  generally,  and 
the  medical  journals  contain  many  reports  of  cases  successfully 
treated  in  this  manner.  Inflation  as  compared  with  liquid  injec- 
tions produces  a  more  equable  and  ett'ective  distension  of  the 
external  or  incarcerating  portion  of  intestine,  and  cases  of  cure 
by  inflation  have  been  reported  after  injections  had  failed.  Treat- 
ment by  inflation,  which  indeed  ought  to  occur  to  any  intelligent 
physician,  appreciating  the  anatomical  condition  of  the  parts,  as 
the  correct  mode,  was  prominently  brought  to  the  notice  of  the 
profession  in  modern  times  by  Mr.  Samuel  Mitchell,  in  a  commu- 
nication to  the  London  Lancet  for  March  17th,  1838. 

"I  take  the  liberty,"  he  writes,  "  of  suggesting  to  the  profession, 
through  the  medium  of  your  valuable  periodical,  the  trial  of 
inflating  the  bowels  by  means  of  a  glyster-pipe  attached  to  a 
common  pair  of  bellows ;  it  has  fallen  to  my  lot  to  witness  several 
of  these  most  distressing  cases  in  children;  the  nature  of  the 
obstruction  was  foretold  during  life,  and  unfortunately  verified  by 
post-mortem  examination.  The  last  case  of  the  kind  which  came 
under  my  care,  about  two  years  since,  presented  all  the  usual 
sjaiiptoms:  intolerable  restlessness,  the  most  obstinate  sickness, 
the  singularly  distressed  state  of  countenance,  and  shrunken 
features.  The  usual  remedies  were  had  recourse  to,  viz.,  warm 
baths,  glysters,  anodyne  frictions  over  the  abdomen,  etc.,  but 
without  avail.  As  a  forlorn  hope  I  made  trial  of  inflation  by  the 
above  means,  with  the  most  happy  result.  The  sickness  immedi- 
ately ceased;  the  child  within  an  hour  passed  a  natural  stool,  and 
in  the  morning  was  almost  without  ailment." 

This  mode  of  treatment  is  termed  novel  in  the  Lancet,  but  it  is 
really  as  old  as  the  time  of  Hippocrates,  who  speaks  of  throwing 
air  into  the  bowels,  by  which  fl.atulence  is  imitated  (flatus  immi- 
tatur).  {Hippocrates'  Works,  translated  from  the  Greek  by  Grimm, 
4  bd., page  198.)  Haller  also  recommended  the  same  treatment: 
"Flatus  etiam  immissus  celerime  susceptionem  dispellet."  {Physi- 
ologia  Corporis  Humani,  tom.  vii.  p.  95.)  In  the  Ldinburgh  ITedical 
Journal,  October,  1864,  Dr.  David  Greig  relates  five  cases  of  suc- 
cessful treatment  of  intussusception  by  inflation.  The  first,  an 
infant  six  months  old,  previously  in  good  health,  suddenly  became 
very  fretful,  apparently  having  severe  paroxysmal  pain  in  the 
abdomen.  She  had  vomiting,  and  finally  tenesmus,  with  bloody 
evacuations.  Warm  water  enemata  could  not  be  administered  on 
account,  the  writer  thinks,  of  the  spasmodic  action  of  the  intestines, 
and  an  abdominal  tumor  could  be  distinctly  felt  near  the  umbilicus. 


670  INTUSSUSCEPTION. 

Castor  oil  and  a  purgative  powder,  and  enemata  of  water  having 
been  employed  in  vain,  and  the  case  becoming  really  critical  on 
the  second  day,  inflation  was  employed.  The  writer  says:  "The 
nozzle  of  a  small  pair  of  bellows  was  introduced  into  the  anus, 
and  air  injected  to  a  considerable  extent.  Contrary  to  our  expec- 
tation, the  air  passed  readily  into  the  bowel,  and  seemed  to  give 
the  child  great  relief.  After  the  injection  it  lay  very  quiet,  as  if 
asleep,  and  evidently  quite  free  from  pain.  In  about  twenty 
minutes  from  the  time  the  air  injection  was  administered  a  slight 
rumbling  noise  was  heard  in  the  child's  abdomen,  followed  by  a 
crack  so  loud  and  distinct  as  to  alarm  the  attendants  in  the  room, 
who  thought  something  had  burst  in  the  child's  bowels.  The 
child,  however,  continued  as  if  asleep  and  free  from  pain,  and  in 
about  half  an  hour  a  large  feculent  stool,  slightly  mixed  with 
blood  and  mucus,  was  passed  without  pain.  During  the  night  the 
child  rested '  pretty  well,  had  no  return  of  vomiting,  took  the 
breast  as  usual,  and  in  two  days  was  quite  well." 

Another  child  nine  months  old,  treated  by  Dr.  G-reig,  presenting 
nearly  the  same  S3^mptoms  and  the  abdominal  tumor,  also  obtained 
relief  by  inflation,  after  castor  oil  and  enemata  had  failed  to  pro- 
duce any  benefit. 

An  apparatus  for  the  production  and  injection  of  carbonic  acid 
gas  has  been  invented  by  Schultz  and  "Warker,  of  this  city,  and  is 
manufactured  by  them.  It  consists  essentially  of  two  glass 
chambers,  one  over  the  other.  In  the  lower  one  a  bicarbonate  is 
placed,  and  in  the  upper  an  acid  in  a  liquid  state.  By  the  gradual 
admixture  of  the  two,  carbonic  acid  is  set  free.  An  elastic  tube 
conveys  the  gas  from  the  lower  chamber.  This  apparatus  has 
been  used  by  j)hysicians  of  the  city,  for  the  reduction  of  intussus- 
ception and  other  purposes,  and  is  a  useful  invention. 

The  same  firm,  and  several  others  in  this  city,  prepare  for  the 
shops  quart  bottles  of  highly  charged  carbonic-acid  water,  from 
which  when  inverted  a  powerful  current  of  carbonic  acid  gas  can 
be  obtained.  Two  or  three  of  these  bottles,  with  a  portion  of  the 
tube  from  Davidson's  syringe,  which  can  be  readily  attached  to  the 
stem  from  which  the  gas  escapes,  constitute  all  that  is  required  for 
an  ordinary  case. 

The  following  cases,  which  I  treated  with  Dr.  Biichler,  of  this 
city,  in  1871,  show  what  may  be  achieved  by  inflation,  and  also 
the  unfavorable  result  which  must  inevitably  occur  in  certain 
cases.  A  German  infant,  five  months  old,  nursing,  began  to  be 
fretful,  crying  often  on  March  7th,  and   before  night   passed   a 


TREATMENT.  671 

scanty  motion  of  l)loo(L  The  symptoms  continuing,  I  was  asked 
to  examine  the  infant  on  the  10th,  and  learned  the  following  facts: 
It  hud  vomited  daily,  had  had  daily  scanty  but  infrequent  stools, 
consisting  chiefly  of  blood,  accompanied  at  first  by  tenesmus,  but 
not  within  the  last  day;  it  continued  to  nurse,  but  was  becoming 
thinner  and  weaker,  and  was  evidently  in  pain.  The  symptoms 
indicating  the  nature  of  the  disease,  the  abdomen,  which  was  not 
distended,  was  examined  for  the  tumor,  which  was  found  in  the 
right  side  in  the  site  of  the  ascending  colon,  apparently  about  one 
and  a  half  to  two  inches  in  length;  pulse  124  in  sleep;  no  cough. 
An  ineffectual  attempt  was  made  to  reduce  the  intussusception  by 
a  very  rude  and  imperfectly  constructed  apparatus  (the  bellows), 
when  from  the  lateness  of  the  hour  farther  treatment  was  post- 
poned till  early  the  following  morning,  11th.  Tumor  still  detected 
in  the  right  lumbar  region ;  pulse  120  asleep,  150  awake.  By  means 
of  Schultz  and  Warker's  apparatus,  the  intestines  were  inflated  so 
as  to  produce  very  decided  prominence  of  the  abdomen,  and  the 
abdomen  gently  kneaded.  After  some  minutes  the  gas  was 
allowed  to  escape,  when  the  tumor  had  disappeared.  In  a  few 
hours,  a  natural  evacuation  occurred  from  the  bowels,  and  the 
infant  has  remained  well  since. 

The  second  case  ended  unfavorably,  although  the  symptoms 
were  apparently  no  more  grave  than  in  the  case  just  related,  and 
had  continued  a  shorter  time.  This  infant  was  also  of  German 
parentage.  The  tumor,  firm  and  elongated,  could  be  distinctly  felt 
in  the  left  lumbar  region.  In  this  case  the  inverted  bottles  of 
carbonic-acid  water  were  employed,  and  when,  after  considerable 
delay  and  kneading  of  the  abdomen,  the  gas  was  allowed  to  escape 
from  the  intestine,  the  tumor  had  disappeared.  A  few  hours 
afterwards  convulsions  occurred  ending  fatally.  At  the  autopsy 
the  invaginated  mass,  which  was  too  firmly  strangulated  to  admit 
of  reduction  by  inflation,  was  found  in  the  epigastric  region,  having 
been  carried  up  from  its  former  position  by  the  inflation  of  the 
intestine  below.  It  consisted  of  the  terminal  part  of  the  ileum, 
which  had  passed  through  the  ileo-coecal  orifice,  and  become  incar- 
cerated in  the  ascending  colon,  and,  as  is  not  unusual  in  these  cases, 
the  action  of  the  intestines  had  changed  the  location  of  the  tumor 
in  the  abdomen  from  the  right  to  the  left  side. 

Whether  air  or  carbonic  acid  is  employed,  it  is  necessary  to 
produce  distension  of  the  intestine  to  its  fullest  extent  below  the 
seat  of  the  complaint,  without  endangering  rupture,  and  of  course 
the  sooner  it  is  used  the  better  the  chance  of  success.     In  two  or 


672  INTUSSUSCEPTION. 

three  days  the  inverted  intestine  has,  in  a  larger  proportion  of 
cases,  become  so  firmly  incarcerated,  and  has  descended  so  far,  that 
attempts  to  replace  it  are  unsuccessful ;  still,  even  at  a  late  period, 
a  persevering  attempt  should  be  made,  if  it  has  not  been  previously 
tried. 

If,  in  the  failure  of  inflation  to  reduce  the  intussusception,  injec- 
tions of  water  are  employed,  the  thighs  should  be  elevated  above  the 
shoulders  in  order  to  obtain  the  aid  of  gravitation,  but  if  inflation 
is  unsuccessful,  probably  the  less  effectual  method  of  injection  will 
fail  also.  The  employment  of  quicksilver  by  the  rectum  with  the 
thighs  elevated  has  been  suggested  to  me  as  a  dernier  ressort.  This 
may  be  a  useful  suggestion,  especially  for  those  cases  in  which  the 
intussusception  occurs  in  the  descending  colon. 

When  the  above  measures  have  failed  to  relieve  the  patient,  it 
has  been  proposed  to  cut  down  upon  and  replace  the  intestine,  in 
the  same  way  as  the  surgeon  treats  strangulated  hernia,  and  this 
oi'teration  is  said  to  have  been  successfully  performed  in  the  adult. 
If  the  tumor  can  be  readily  detected  by  external  examination,  if 
its  position  be  favorable  and  the  patient  an  adult,  the  propriety  of 
such  an  operation  might  be  seriously  considered,  but  I  apprehend 
that  there  are  few  surgeons  at  the  present  day  who  would  perform 
or  recommend  this  mode  of  treatment  in  the  child.  The  child, 
and  especially  the  infant,  could  hardly  recover  from  the  shock  of 
so  severe  an  operation,  even  if  it  escaped  peritoneal  inflammation. 
As  an  objection  to  the  use  of  the  knife  is  the  important  fact,  which 
distinguishes  intussusception  from  hernia,  that  sloughing,  which 
finally  occurs  if  life  is  prolonged,  is  conservative  in  the  former, 
though  fatal  in  the  latter.  After  failing  to  return  the  intestine  by 
the  mode  described  above,  active  measures  should  be  discontinued, 
and  the  treatment  should  be  expectant.  Recollecting  that  death 
is  from  asthenia,  and  that  after  a  certain  time,  if  the  strength  holds 
out,  adhesive  inflammation  occurs,  and  the  mass  which  closes  the 
intestine  sloughs  and  is  expelled,  we  should  endeavor  to  sustain 
the  vital  powers  by  nutriment  and  stimulants,  and  relieve  the  pain 
by  the  judicious  use  of  opiates.  At  this  stage  of  the  complaint 
there  is  local  peritonitis  between  the  coats  of  the  intussusception, 
and  this  requires  the  administration  of  opium  in  some  form. 
Sustaining  and  expectant  measures  ought  to  be  adopted  at  an  early 
period.  The  diet  should  consist  of  beef  essence  or  other  concen- 
trated nutriment  which  leaves  little  residuum. 

Vomiting,  which   is   so  constant,  requires   no  treatment.      It 


TREATMENT.  G73 

relieves  the  distension  and  prevents  fascal  accumulation,  which, 
pressing  downwards,  increases  the  extent  of  the  invagination  and 
counteracts  the  eftect  of  the  injections.  Convulsions  are  to  be 
treated  by  the  local  measures  which  are  apj^ropriate  when  they 
occur  under  other  circumstances.  At  first  no  external  treatment  is 
required  over  the  seat  of  the  invagination,  but,  when  the  abdomen 
becomes  tender  and  painful  from  the  local  peritonitis,  poultices  are 
of  service. 


43 


SECTION  lY. 

DISEASES  OF  CIECULATORY  SYSTEM. 


CHAPTER  I. 

CYANOSIS. 


Certain  of  the  diseases  which  pertain  to  the  circulatory  system 
have  been  treated  of  in  other  parts  of  this  book  (umbilical  hemor- 
rhage, gastro-intestiual  hemorrhage,  etc.).  It  remains  to  consider 
that  o-eneral  condition  of  the  blood  which  is  desis-inated  morbus 
ceeruleus  or  cyanosis. 

In  1863, 1  read  before  the  jSTew  York  Academy  of  Medicine  a 
statistical  paper  on  cyanosis,  which  was  published  in  the  Trans- 
actions of  that  Society.  This  paper  contains  an  analysis  of  191 
cases,  collated  from  the  various  European  and  American  medical 
journals,  and  to  these  cases  I  am  indebted  for  most  of  the  follow- 
ing facts  pertaining  to  this  disease. 

The  term  cyanosis  or  blue  disease  is  differently  employed  by 
writers.  Some  apply  it  to  cases  of  transient  lividity  occurring  in 
the  course  of  acute  diseases,  as  well  as  to  those  cases  which  depend 
on  permanent  structural  changes,  or  on  malformations.  I  apply 
this  term,  as  do  most  pathologists,  only  to  the  latter  eases. 

Some  are  inclined  to  discard  the  consideration  of  cyanosis  as  a 
disease,  regarding  it  rather  as  a  symptom.  Their  view  is,  in  my 
opinion,  correct  in  reference  to  the  cyanotic  state,  which  occurs  in 
certain  acute  diseases,  but  not  in  reference  to  cyanosis,  as  I  have 
defined  the  term  and  employ  it.  The  propriety  of  considering  cya- 
nosis a  disease  is  more  apparent  if  we  are  not  misled  by  the  term 
which  designates  it.  Lividity  is  not  its  most  important  or  its  es- 
sential characteristic.  It  is  simply  a  sign,  although  conspicuous, 
and,  indeed,  the  only  one  by  which  the  disease  can  be  readily  recog- 
nized. Cyanosis  is,  in  reality,  a  blood  disease,  its  pathological 
state  consisting  in  a  deficient  oxygenation  of  this  fluid,  or  in  an 
excess  in  it  of  carbonic  acid,  and  probably  of  carbonaceous  products. 


LITERATURE    OF    CYANOSIS.  675 

It  should  be  placed  in  the  same  category  with  leucocythemia  and 
melanremia. 

Statistics  show  that  cyanosis  is,  with  very  few  exceptions,  due 
to  malformation  in  the  circulatory  system,  and  at  the  centre  of 
circulation,  namely,  in  the  heart  and  in  the  large  vessels  which 
arise  from  this  organ.  In  the  exceptional  cases,  the  cause  of  the 
cyanosis  is  located  in  the  lungs,  and  is  in  all  or  nearly  all  in- 
stances either  extensive  emphysema  in  both  lungs,  firm  and  thick 
fibrinous  exudation  over  both  lungs,  compressing  them  by  its  con- 
traction and  causing  perhaps  carnification  in  parts  of  them,  or  the 
cause  is  compression  of  the  lungs  from  caries  of  the  vertebrae,  and 
consequent  depression  of  the  ribs.  These  causes  pertain  to  youth 
and  manhood,  rather  than  to  infancy  and  childhood.  On  account 
of  this  fact  and  the  rarity  of  such  cases  they  need  not  be  considered 
in  this  connection. 

Literature  of  Cyanosis. 

The  ancient  j^hysicians,  so  far  as  can  be  ascertained  from  their 
writings  still  extant,  were  ignorant  of  cyanosis ;  whether  they 
overlooked  it,  or  whether  those  early  ages  were  exempt  from  it, 
and  the  malformation  on  which  it  depends  is  peculiar  to  a  pos- 
terity physically  degenerate.  The  blue  disease  described  by  Hip- 
pocrates {De  Morbis,  lib.  ii.  Sec.  v.  page  485,  Ed.  de  Foe's,  1621) 
was  probably  some  acute  febrile  afiection.  Galen,  whose  volumi- 
nous writings,  with  an  excellent  index,  are  still  extant,  and  whose 
comprehensive  mind  embraced  the  whole  range  of  medical  science 
of  the  second  century,  makes  no  mention  of  it,  so  far  as  I  can  find. 
In  the  middle  ages,  as  appears  from  a  remark  of  Boerhaave  {Dis- 
eases of  the  Humors^  Acad.  Lect.  §  732),  the  common  people  believed 
the  cyanotic  to  be  the  victims  of  evil  spirits ;  and  it  is  probable 
that  physicians,  during  this  long  period  of  superstition  and  intel- 
lectual lethargy,  embraced  the  popular  belief. 

On  the  revival  of  learning,  pathological  anatomy  began  to  be 
more  thoroughly  and  intelligently  studied  ;  but  it  is  evident  that 
before  the  great  discovery  of  Harvey,  in  the  17th  century,  it  was 
impossible  to  refer  cyanosis  to  its  true  cause.  In  the  latter  part 
of  the  century  so  auspiciously  opened  by  Harvey's  genius,  mal- 
formations of  the  heart  were  observed  and  described  by  some 
j^athologists  on  the  continent,  in  cases  in  which  cyanosis  must 
have  been  present ;  but  it  is  uncertain,  from  the  brief  records 
which  they  have  left,  whether  any  of  them  understood  the  de- 


676  CYANOSIS. 

pciidence  of  this  disease  on  the  abnormal  state  of  the  heart.     Boer- 
haave,  in  the  beginning  of  the  18th  century,  attributes  "  a  livid  or 
black  color  diffused  throughout  the  whole  skin,"  evidently  refer- 
rino-  to  cyanosis,  to  "  1,  a  relaxation  of  the  vessels,  while  the  vis  a 
tcrgo  remains  the  same,  or,  2,  to  a  too  sudden  increased   pressure 
behind,  without  a  relaxation  of  the  vessels."     Vieussens,  who  was 
a  contemporary  of  Boerhaave,  and  was  more  thorough  in  the  ex- 
amination of  morbid  as  well  as  healthy  structures,  narrated  the 
history  of  a  cyanotic  patient,  with  a  description  of  the  malforma- 
tion, but  the  one  who  first  gave  particular  attention  to  the  blue 
disease  was  Morgagni.     This  Paduan  professor,  far  excelling  his 
l^redecessors  in  thoroughness  of  observation  and  accuracy  of  deduc- 
tion, published  a  theory  in  explanation  of  the  disease  which  now, 
after  the  lapse  of  more  than  a  century,  has  many  adherents.     In 
the  same  century  with  Morgagni,  the  18th,  but  subsequently  to 
his  time,  Drs.  Pulteney,  Wm.  Hunter,  BailUe,  Wilson,  and  Aber- 
nethy  in  Great  Britain,  and  Jurine  and  Sandifort  on  the  continent, 
may  be  mentioned  among  those  who  contributed  to  a  knowledge 
of  cyanosis  by  the  publication  of  cases,  with  a  description  of  the 
malformations.     Yet,  when  the   present  century  commenced,  no 
monograph  or  dissertation  had  appeared  on  this  disease  ;  and,  not- 
withstanding the  publication  of  cases  from  time  to  time,  the  profes- 
sion generally  were  almost  totally  unacquainted  with  its  nature. 
No  better  idea  can  be  given  of  the  prevailing  ignorance  in  reference 
to  cyanosis  at  this  period  than  by  quoting  from  a  case,  narrated  by 
Ribes  in  1814.     {Bull  de  la  Fac.  de  31ed.,  Paris,  1815.)     The  patient 
had  some  time  previously  received  an  injury  of  the  finger.     "  Many 
physicians  of  Amsterdam,"  says  he,  "  were  at  difterent  times  con- 
sulted on  the  subject  of  this  aftection,  no  one  of  whom  understood 
its  true  cause,  its  essential  character.  One  considered  it  as  partaking 
of  the  nature  of  epilepsy,  and  caused  by  the  irritation  in  the  ner- 
vous system  which  the  wound  in  the  finger  had  produced.     Others 
attributed  it  to  the  presence  of  intestinal  worms.    Some  physicians 
pronounced  it  an  injury  of  the  liver  or  spleen.     Many  held  it  to 
be  a  scorbutic  affection.     One  only  believed  it  to  be  the  result  of 
an  unknown  organic  disease." 

Since  the  commencement  of  the  present  century  the  blue  disease 
has  received  a  large  share  of  attention.  According  to  Forhes's 
Medical  Biography^  the  first  dissertation  on  this  subject  appeared 
in  1805,  from  the  pen  of  Seller,  and  from  this  time  till  1832  no 
fewer  than  twenty-eight  dissertations  or  monographs  were  pub- 


LITERATURE    OF    CYANOSIS.  077 

lislicd,  cither  on  cyanosis,  or  on  malformations,  which  produce  it 
or  at  least  relate  to  it.  In  the  list  of  writers  are  some  of  the  most 
eminent  names  in  the  profession,  as  Louis  and  Bouillaud.  The 
numher  who  have  written  on  this  suhject  since  1832  probably 
exceeds  the  number  of  previous  writers.  Of  those  who  have  con- 
tributed most  to  our  knowledge  of  the  disease  may  be  mentioned 
Farre,  Chevers,  and  Peacock  in  Great  Britain,  Gintrac  on  the 
continent,  and  Moreton  St\\\6  in  this  country.  Farre,  Chevers,  and 
Peacock  wrote  on  malformations  of  the  heart,  alluding  incidentally 
to  cyanosis,  but  their  writings  contain  valuable  matter  for  statistics 
bearing  on  the  latter  subject.  Farre's  book  was  published  in  1814, 
and  is  out  of  print ;  Chevers  published  his  papers  in  the  London 
3Ied.  Gazette^  commencing  in  the  year  1845,  and  running  through 
several  successive  volumes.  Peacock's  Treatise  was  published  in 
1858.  It  contains  several  original  cases,  previously  narrated  by 
him  to  the  London  Pathological  Society.  The  paper  by  Moreton 
Stille,  which  has  attracted  much  attention,  especially  in  Europe, 
was  his  Inaugural  Thesis,  and  was  published  in  the  Amer.  Journ. 
of  Med.  Sci.^  in  1844.  This  paper  relates  entirely,  in  the  words  of 
the  author,  to  "the  laws  of  the  causation  of  cyanosis."  The  only 
really  complete  statistical  paper  on  the  blue  disease  is  that  by  M. 
Gintrac,  published  in  1824,  in  Paris,  and  embracing  all  the  cases, 
which  had  been  accurately  reported  up  to  that  time,  namely,  fifty- 
three.  He,  indeed,  exhausted  the  subject  for  the  period  in  which 
he  wrote,  and  were  it  not  for  the  accumulation  of  material  since, 
little  could  be  added  to  his  essay. 

Two  theories  in  explanation  of  the  occurrence  of  cyanosis  have 
divided  the  profession ;  the  one  attributing  it  to  obstruction  at 
the  centre  of  circulation,  and  consequent  venous  congestion :  the 
other,  to  admixture  of  venous  and  arterial  blood  through  openings 
in  the  septa  of  the  heart,  or  through  the  ductus  arteriosus.  The 
former  of  these  theories  ori2:inated  with  Moro-ao-ni  more  than  one 
hundred  years  ago,  and  is  essentially  the  same  as  that  advocated 
by  Stills.  Stilld  errs  in  placing  Morgagni  among  the  advocates  of 
the  other  system.  The  second  theory,  or  that  which  attributes 
cyanosis  to  admixture  of  venous  and  arterial  blood,  is  said  by  Dr. 
Peacock  to  have  originated  with  Hunter,  but  its  ablest  supporter 
was  Gintrac.  Of  late  there  are  some  pathologists  who  do  not 
believe  that  either  theory  is  sufficient  to  explain  the  cause  of 
cyanosis,  but  that  the  true  explanation  lies  somewhere  between 
the  two.  Among  the  most  conspicuous  of  these  is  Prof.  Walshe 
of  London.    These  theories  will  be  considered  in  the  proper  places. 


678  CYANOSIS. 

Sex. — Writers  on  cj^anosis  state  that  there  is  a  preponderance 
of  males  to  females  affected  with  it.  Aberle  of  Vienna  says  that 
two-thirds  were  males  in  an  aggregate  of  180  cases  which  he  col- 
lated. In  Gintrac's  cases,  28  were  males  and  16  females;  in 
Stilld's,  41  were  males  and  31  females.  The  sex  is  recorded  in  134 
of  the  cases  collected  by  me,  of  which  78  were  males,  56  females; 
and  if  those  cases  are  excluded  in  which  cyanosis  was  due  to 
obstruction  at  the  mouth  of  the  pulmonary  artery,  the  number  of 
the  two  sexes  is  the  same.  In  the  five  years  commencing  with 
1858,  according  to  the  mortuary  returns,  207  died  in  this  city 
from  cyanosis,  of  which  number  117  were  males,  90  females.  In 
England,  for  two  years,  418  males  died  of  cyanosis,  and  273  females. 
Although  statistics  of  difierent  cities  and  countries  agree  in  the 
fact  of  an  excess  of  males  over  females,  there  does  not  appear  to 
be  that  great  preponderance  of  males,  which  the  earlier  writers  on 
this  disease  believed  to  exist. 

Causes  of  the  Malformations. — Mothers  sometimes  attribute 
the  malformations,  and  probably  correctly,  to  strong  mental  im- 
pressions felt  during  utero-gestation.  The  mother  of  a  patient 
treated  by  Dr.  Peacock  stated  that,  "  two  months  before  her  con- 
finement, she  was  frightened  by  seeing  a  child  killed,  and  never 
recovered  from  the  shock  she  sustained."  {Malf.  of  Hearty  p.  37.) 
In  another  case  "the  mother  was  much  out  of  health,  and  stated 
that,  when  pregnant  with  the  child,  she  was  greatly  alarmed  by 
seeing  a  man  who  was  dying  of  asthma."  (Op.  cit.,  page  57.)  In 
another  instance  the  mother  was  frightened  at  the  fifth  month  of 
pregnancy  (page  41) ;  and  in  still  another  case,  recorded  by  Dr. 
Peacock,  the  mother,  four  or  five  months  before  her  confinement, 
"was  greatly  alarmed  by  her  husband,  who  was  insane,, standing 
over  her  for  two  hours  with  a  loaded  pistol."    (Page  43.) 

Occasionally  the  malformation  appears  to  be  due  to  some  vice 
or  taint  in  the  system  of  one  or  both  parents.  In  a  case  quoted 
in  the  Gazette  Medicale  for  December  28th,  1850,  from  another  con- 
tinental journal,  it  is  stated  that  "  the  mother,  who  had  formerly 
suficred  from  rickets,  gave  birth  to  five  children,  all  of  whom  died 
immediatel}'-  or  shortly  after  birth  with  symptoms  of  cyanosis. 
The  father  died  at  the  age  of  thirty-six  of  phthisis."  Dr.  Peacock 
relates  a  case  in  which  the  father  was  livid,  and  had  the  "  pigeon- 
breast"  common  in  the  cyanotic.  In  the  history  of  a  patient, 
which  was  communicated  by  Cooper  to  Farre  (Case  166),  it  is 
related  that  "  vices  of  conformation  of  the  heart  appeared  to  have 
been  inherent  in  the  family.     Of  12  infants  only  4  survived,  and 


CAUSES    OF    THE    MALFORMATIONS.  679 

more  presented  signs  of  heart-disease."  Dr.  Buchanan  relates  the 
history  of  a  child  which  was  the  second  that  had  suffered  and  died 
in  the  same  family  in  the  same  way  (Case  40).  A  patient  treated 
by  Mr.  Leonard  was  the  sixth  child  of  the  family,  who  had  died 
at  about  the  some  age,  with  symptoms  of  cyanosis.  Such  instances 
are,  however,  exceptional.  Ordinarily,  the  cyanotic  have  not  only 
healthy  jmrents  but  healthy  brothers  and  sisters.    * 

A  patient  whose  history  is  given  by  Dr.  William  Hunter  was 
born  at  the  eighth  month,  but  in  nearly  all  other  cases  the  full 
period  of  uterine  existence  was  reached. 

The  opinion  was  expressed  by  Gintrac  that  the  number  affected 
with  cyanosis,  to  the  entire  population,  varies  in  different  coun- 
tries. It  is  probable  that  the  occurrence  of  the  blue  disease  is  not 
greatly,  if  at  all,  influenced  by  the  nationality,  but  it  is  certainly 
dependent  to  a  considerable  extent  on  the  condition  of  society.  It 
is  less  frequent  in  a  community  in  comfortable  circumstances,  and 
engaged  in  wholesome  and  quiet  occupations.  Pure  air  and  out- 
door exercise,  plain,  nutritious  diet,  freedom  from  cares  and 
anxieties,  in  fine,  causes  which  promote  the  physical  well-being, 
diminish  the  liability  to  an  ill-formed  and  cyanotic  offsi^ring. 
And,  conversely,  impure  air,  improper  and  insufficient  diet,  grief, 
etc.,  increase  the  percentage  of  cyanotic  cases.  Hence,  it  is  a  rare 
disease  in  the  rural  districts,  and  comparatively  frequent  in  the 
cities,  especially  in  a  large  city  like  l^ew  York,  which  contains  a 
numerous  indigent  and  careworn  population,  living  from  year  to 
year  in  the  midst  of  agencies  which  operate  stealthily  but  certainly 
to  enervate  the  system  and  undermine  the  health. 

These  remarks  are  abundantly  substantiated  by  statistics.  In 
New  York  City  for  the  six  years  ending  with  1860,  there  was  one 
death  from  cyanosis  to  436  deaths  from  all  causes ;  and  in  Brooklyn 
the  x^roportion  estimated  for  two  years  was  about  the  same.  On 
the  other  hand,  in  the  State  of  Kentucky,  which  contains  few  large 
cities,  and  in  the  death  reports  of  which  cyanosis  is  included  in  the 
general  term  malformation,  there  was,  during  a  period  of  five  years, 
one  death  from  malformation  to  2469  from  all  causes.  In  the  State 
of  South  Carolina,  for  three  years,  there  was  one  death  from  cya- 
nosis to  5018  from  all  causes.  In  the  State  of  Massachusetts,  for 
two  years,  there  was  one  death  from  cyanosis  to  1136  from  all 
causes,  and  two-thirds  of  the  cyanotic  cases  occurred  in  the  coun- 
ties of  Sulfolk,  Essex,  and  Worcester,  which  contain  large  cities. 
In  London  there  was  one  death  from  cyanosis  to  755  from  all 
causes  during  a  period  of  three  years.     On  the  other  hand,  in  Eng- 


680 


CYANOSIS. 


land,  including  the  city  of  London,  there  was,  for  the  ten  years 
ending  with  1857,  one  death  from  cyanosis  to  1589  from  all  causes  ; 
and  in  the  rural  districts  of  Monmouth  and  Wales  there  was  onlv 
one  death  from  cyanosis  to  5578  deaths  from  all  causes  during  a 
period  of  two  years. 

Time  of  Commencement. — It  is  an  interesting  and  somewhat 
remarkable  fact 'that  cyanosis,  though  dependent  on  a  malforma- 
tion, does  not  always  commence  at  birth,  or,  at  least,  that  it  does 
not  exist  in  degree  sufficient  to  produce  the  cyanotic  hue  till  some 
time  has  elapsed  after  birth.  In  138  of  the  cases  of  cyanosis  which 
I  have  collected,  the  time  at  which  lividity  was  first  observed  is 
stated  as  follows:  In  97  it  was  within  the  first  week,  and  generally 
within  a  few  hours  of  birth.  In  the  remaining  41  cases  it  com- 
menced as  follows : — 


;n  3  at  2  weeks. 

In  6  from  2  years 

to  5  3 

/•ea 

"  1   "3       " 

"  1     "      5     " 

"10 

(( 

"  2  "1  month. 

"  6     "    10     " 

"20 

(1 

"  7  from  1  to  2  months. 

"  1     "    20     " 

"40 

u 

"5     "     2  "  6      " 

"  1  over  40  years, 

"  5     "    6  "12      " 

— 

"3     "     1  year  to  2  years. 

41 

In  these  41  cases,  in  which  blueness  did  not  occur  till  after  the 
age  of  one  week,  if  the  patient  were  less  than  two  years  old  when 
it  commenced,  there  was  frequently  no  obvious  exciting  cause, 
but  above  this  age,  with  three  exceptions,  such  a  cause  is  known 
to  have  been  present.  It  is  interesting  to  observe  how  trivial 
the  exciting  cause  frequently  is,  and  equally  interesting  to  note 
how  long  patients  have  enjoyed  good  health,  not  having  the  least 
lividity,  although  the  anatomical  vice,  to  which  the  final  develop- 
ment of  cyanosis  was  due,  had  existed  from  birth. 

Dr.  Theophilus  Thompson  relates,  in  the  Medico-Chir.  Trans. ^ 
vol.  XXV.,  the  history  of  a  lady,  thirty-eight  years  old,  who  was 
well  till  an  attack  of  Asiatic  cholera,  after  which  her  health  was 
permanently  impaired.  Two  years  before  her  death  she  passed 
through  a  course  of  fever,  and  from  this  time  was  cyanotic.  In 
the  Philadelphia  3Ied.  Examiner.,  June,  1850,  Dr.  "Waters  relates  a 
case,  in  which  cyanosis  began  at  the  age  of  six  years  in  an  attack 
of  measles.  In  a  case  pul^lislied  by  Mr.  iS'apper,  in  the  London 
3Iedical  Gazette.,  1841,  the  child  fell  at  the  age  of  six  months,  and 
from  this  time  had  cyanosis.  A  female,  whose  history  is  given  by 
Prof.  Tommasini,  of  Bologna,  and  quoted  by  Bouillaud,  became 
cyanotic  at  the  age  of  twenty-five  in  consequence  of  difficult  par- 


SYMPTOMS.  681 

turition.  In  the  London  Lrmcd^  1842,  Mr.  Stodman  relates  a  case, 
in  wliich  cyanosis  began  at  the  age  of  ten  weeks  in  an  attack  of 
convulsions.  In  the  Amerieayi  Journal  of  Med.  Sciences,  1847,  Dr. 
John  P.  Harrison  published  the  history  of  a  baker,  twenty  years 
old,  in  whom  cyanosis  began  five  years  previously  after  great 
effort  in  carrying  wood.  Louis  and  Bouillaud  quote  from  M. 
Caillot  the  case  of  a  child,  who  became  cyanotic  at  the  age  of  two 
months  in  an  attack  of  hooping-cough.  Louis  also  narrates  a  case 
in  which  hooping-cough  had  the  same  effect  at  the  age  of  twelve 
years.  Eibes  treated  a  child  in  whom  the  blue  disease  began  at 
the  age  of  three  years  from  a  severe  contusion  of  the  fingers.  In 
a  case  related  by  Marx  it  commenced  at  the  age  of  ten  months 
from  a  blow  on  the  back,  inflicted  b}^  the  mother.  In  the  Medical 
Times  and  Gazette  for  1855  Mr.  Speer  gives  the  history  of  a  female, 
who  at  the  age  of  thirteen  years  was  put  in  a  place  requiring  con- 
siderable exertion,  and  from  this  time  was  cyanotic.  A  patient, 
whose  case  is  narrated  b}'^  Cherrier,  fell  into  a  deep  ditch  in  the 
winter  season,  and  immediately  after  had  a  low  fever,  from  which 
the  blue  disease  commenced.  In  a  case  published  by  Tacconus  the 
exciting  cause  was  believed  to  be  fright,  in  consequence  of  a  fall 
from  a  great  height,  and  in  another,  related  by  Bouillaud,  it  was 
a  blow  received  on  the  epigastrium  after  the  patient  had  passed 
the  age  of  fifty  years.  Similar  cases  are  related  by  Mayo  and 
Peacock. 

It  will  be  seen  that  the  exciting  cause  of  cyanosis  is  usually 
such  as  produces  a  profound  impression  on  the  system,  and  affects 
the  action  of  the  heart.  Precisely  in  what  way  it  operates  to 
develop  the  disease .  has  not  been  satisfactorily  explained.  Mr. 
Mayo  conjectures,  that  in  the  case  related  by  him  there  was  pre- 
viously some  compensation  which  ceased,  or  became  inadequate  in 
consequence  of  some  change  produced  in  the  economy.  Although 
cyanosis  may  not  appear  for  months  or  even  years,  there  is  rarely 
improvement  when  it  is  once  established.  Appearances  of  amend- 
ment are  deceptive.  The  disease  when  not  stationary  is  progres- 
sive, and  this  explains  the  fact,  that  few  survive  the  middle  period 
of  life. 

Symptoms. — The  symptoms  of  cyanosis  vary  in  intensity  in 
different  patients,  and  in  the  same  patient  at  different  times,  being 
milder  if  he  is  quiet  and  the  mind  calm,  more  severe  if  active,  or 
if  the  mind  is  agitated.  In  mild  cases,  in  a  state  of  rest,  they 
nearly  or  quite  disappear,  so  that  a  stranger  would  not  suspect 
that  there  was  any  serious  ailment.     They  are  aggravated  by  any 


682  CYANOSIS. 

cause  which  accelerates  the  action  of  the  heart.  In  some,  cyano- 
sis is  increased  by  the  most  trivial  disturbing  influences,  among 
which  may  be  mentioned  nursing,  dentition,  crying,  coughing,  and 
slight  emotions  of  joy,  sorrow,  or  anger.  In  more  than  one  case  it 
has  been  perceptibly  increased  by  the  stimulus  of  digestion,  the 
color  being  deeper  after  a  full  meal  than  before. 

The  cyanotic  hue  varies  in  diflerent  individuals  from  duskiness 
to  a  deep  purple,  almost  black  color.  It  is  usually  most  marked 
in  the  visage,  especially  the  palpebrge,  cheeks,  nose,  and  lips,  in  the 
ears,  fingers,  and  toes,  and  upon  the  mucous  surfaces.  It  is  some- 
times, without  any  assignable  cause,  confined  to  a  portion  of  the 
body.  In  a  case  related  by  Mr.  Steel  in  the  London  Lancet^  1838, 
the  upper  part  of  the  body  was  livid  and  oedematous,  and  the 
lower  part  pallid  and  shrunken,  and  yet  the  malformation  of  the 
heart  was  that  commonly  present  in  cyanosis.  In  the  London 
Medical  Times,  March  8th,  1845,  copied  from  the  Gazette  Mklicale,  is 
the  history  of  a  child,  six  years  old,  in  whom  the  color  was  deeper 
on  the  right  than  left  side.  There  had  been,  however,  hemiplegia 
of  this  side  in  infancy,  but  this  had  entirely  passed  off.  On  the 
other  hand,  in  a  case  of  rare  malformation  communicated  by 
Cooper  to  Farre,  in  which  the  upper  part  of  the  system  was 
supplied  chiefly  by  arterial  and  the  lower  by  venous  blood,  the 
discoloration  was  general.  In  rare  instances  livid  maculae  have 
been  observed  like  those  of  purpura. 

Those  affiected  with  cyanosis  have  generally  at  birth  been  well 
formed  and  of  the  usual  size,  and  in  most  cases,  for  a  considera- 
ble i:)eriod  after  birth,  the  appetite  is  good,  bowels  regular,  and 
the  system  well  nourished.  But  when  cyanosis  becomes  so  severe, 
as  it  does  sooner  or  later,  that  its  symptoms  are  rarely  absent, 
digestion  is  imperfectly  performed,  and  the  body  becomes  either 
emaciated  or  stunted  and  puny.  It  may  be  stated,  as  a  rule,  that 
nutrition  is  in  inverse  proportion  to  the  gravity  of  cyanosis.  In 
thirty-three  out  of  fortj'-one  cases,  in  which  the  condition  of  the 
system,  as  regards  nutrition,  was  recorded  either  a  short  time  pre- 
viously to  death  or  at  the  autopsy,  the  body  was  either  considerably 
emaciated  or  else  diminutive,  and  those  who  were  well-nourished 
were  usually  such  as  had  died  early,  or  of  some  intercurrent  dis- 
ease. 

In  this  connection  may  be  mentioned  two  abnormalities  which 
have  been  observed  in  the  cyanotic.  The  chest  is  often  flattened 
laterally  with  a  projecting  sternum,  so  as  to  present  an  appearance 
generally  described  in  the  records  as  "  pigeon  breasted."     Some- 


SYMPTOMS.  683 

times  the  most  prominent  part  is  directly  over  the  heart,  and  in 
one  or  two  cases  the  sternum  was  observed  to  be  deflected  towards 
the  left.  In  the  majority  of  the  records,  however,  no  mention  is 
made  of  the  external  appearance  of  the  chest. 

The  other  abnormal  development  is  more  remarkable,  and  has 
not  been  satisfactorily  explained.  In  twenty-eight  cases  it  is 
stated  that  the  tips  of  the  fingers  or  toes,  or  both,  were  bulbous. 
This  hyi:)ertrophy,  if  slight,  is  likely  to  be  overlooked,  and  that  it 
was  observed  and  recorded  in  so  many  cases  renders  it  probable 
that  it  was  present  in  a  much  larger  number.  In  one  case  the  ana- 
tomical character  of  this  enlargement  was  examined,  and  was  found 
to  consist  chiefly  of  hyj^ertrophied  connective  tissue.  The  nails 
are  often  incurvated  over  the  deformitj?-.  At  a  meeting  of  the  Loud. 
Path.  Soe.  in  1859,  Mr.  Ogle  narrated  the  history  of  a  laborer,  fifty 
years  old,  who  had  swelling,  numbness,  and  lividity  of  the  left  arm, 
from  pressure  of  an  aneurism,  and  the  fingers  on  this  side  were 
clubbed  as  in  cyanosis.  A  patient  whose  history  is  related  in  the 
Glasgow  Ilcdical  Journal^  and  who  was  believed  to  be  cyanotic  in 
consequence  of  a  highly  emphysematous  state  of  the  lungs,  had  a 
similar  development  of  the  tips  of  both  fingers  and  toes.  Why  this 
bulbous  growth  should  occur  in  consequence  of  the  circulation  of 
carbonaceous  and  non-oxygenated  blood  must  at  present  remain  a 
mystery. 

An  interesting  feature  in  cyanosis  is  the  low  grade  of  animal 
heat.  The  temperature  of  the  body  is  in  all  cases  below  that  of 
health.  This  is  especially  noticeable  in  the  extremities.  There 
has  not  been  a  sufiicient  number  of  accurate  thermometric  obser- 
vations to  determine  whether  the  internal  heat  is  usually  reduced. 
The  following  only  have  been  recorded :  Mr.  Fletcher  relates  the 
history  of  a  young  man  in  the  3Iedico-Chir.  Trans. ^  vol.  xxv.,  in 
whom  the  thermometer  placed  in  the  mouth  did  not  stand  above 
80°  Fahrenheit.  Hodgson  reports  the  case  of  a  man,  twenty-five 
years  old,  in  whom  the  thermometer  placed  on  the  tongue  rose 
to  100°,  while  in  his  own  case  it  was  two  or  three  degrees  below 
that  term.  In  an  experiment,  recorded  by  !N"asse,  the  instrument 
placed  in  the  mouth  fell  little  if  at  all  below  the  healthy  standard ; 
applied  to  external  parts,  it  stood  at  about  21°  Reaumer. 

The  lack  of  heat  is  the  source  of  great  discomfort  to  a  cyanotic 
patient.  In  mild  weather  he  requires  a  fire  to  keep  him  warm, 
or  an  amount  of  clothing  which  to  others  would  be  intolerable, 
and  in  cold  weather  slight  exposure  strikes  him  with  a  chill.     isTor 


6S4:  CYANOSIS. 

can  lie  increase  his  heat  by  active  exercise,  since   his   infirmity 
disqualifies  him  for  this. 

Although  the  temperature  of  the  surface  is  so  low,  the  occur- 
rence of  perspiration,  sometimes  profuse,  is  mentioned  in  several 
of  the  records. 

In  severe  crises  of  cyanosis  the  generative  system  is  imperfectly 
developed.  In  the  female,  menstruation  is  scanty  or  delayed,  and 
in  the  male  the  signs  of  puberty  are  feebly  manifest.  If  the  dis- 
ease is  so  mild  that  the  symptoms  are  absent  when  the  patient  is 
in  a  state  of  repose,  these  organs  attain  nearly  or  quite  their 
normal  development.  The  catamenia  have  appeared  as  early  as 
the  age  of  sixteen  years ;  and  a  cyanotic  patient  treated  by  Cher- 
rier  had  two  children,  but  they  both  died  of  scrofulous  aflections. 

The  action  of  the  heart  is  necessarily  much  afiected.  In  mild 
forms  of  the  disease,  if  the  patient  is  quiet,  this  organ  may  beat 
with  considerable  slowness  and  regularity,  but  in  all  cases  exer- 
cise or  excitement,  which  in  a  state  of  health  would  scarcely  have 
any  appreciable  effect  on  the  pulse,  embarrasses  its  movements, 
and  produces  palpitation.  In  severe  cases  palpitation  is  rarely 
absent,  and  the  pulse  is  frequent,  feeble,  and  often  intermittent.  In 
a  large  proportion  of  patients  bruits  are  produced  by  the  irregular 
circulation  through  the  heart. 

The  respiration  corresponds  with  the  action  of  the  heart.  It  is 
accelerated  in  proportion  to  the  frequency  of  the  pulse.  The  suf- 
fering in  this  disease  is  largely  due  to  paroxysms  of  palpitation 
and  dyspnoea.  These  occur  sometimes  without  any  apparent  ex- 
citing cause,  and  when  the  patient  is  quiet,  but  they  are  commonly 
induced  by  those  causes  which  we  have  already  mentioned  as 
aggravating  the  symptoms  of  cyanosis.  They  come  on  suddenly, 
and  are  attended  by  increase  of  lividity,  distension  of  the  jugu- 
lars, and  sometimes  of  the  cutaneous  veins,  and  by  a  sensation  of 
present  suffocation.  They  last  only  a  few  minutes,  and  are  suc- 
ceeded by  great  depression  of.  the  vital  powers.  In  infants,  on 
account  of  greater  nervous  irritability,  and  feeble  power  of  endu- 
rance, these  paroxysms  generally  end  in  convulsions,  which  occa- 
sionally are  fatal.  A  cough  is  sometimes  present,  but  it  is  usually 
slight. 

Pain  is  not  a  common  symptom.  Some  of  the  patients  com- 
plained occasionally  of  headache,  with  or  without  vertigo,  and 
occasionally  also  of  pain  in  the  chest,  but  it  is  uncertain  to  what 
extent  or  whether  these  symptoms  were  dependent  on  the  cyanotic 


SYMPTOMS.  685 

disease.  The  secretions  do  not  appear  to  Ije  affected,  so  far  as  lias 
been  ascertained.  The  same  may  be  said  of  the  intellectual  and 
moral  faculties.  In  a  case  related  by  Dr.  Chevers,  the  child  was 
even  said  to  be  precocious.  {Loud.  Med.  Gaz.^  vol.  xxxviii.)  The 
mind  is  cajjable  of  steady  application  and  acquisition,  as  in  health, 
provided  that  the  emotions  are  not  unduly  excited. 

Those  who  are  affected  with  cyanosis  are  liable  to  various  forms 
of  hemorrhage,  but  this  liability,  if  we  may  judge  from  recorded 
cases,  is  greater  in  youth  and  adult  life  than  in  infancy.  In  two 
cases  blood  was  vomited,  in  one  passed  by  stool,  in  one  it  escaped 
from  the  gums,  in  two  from  the  mouth,  in  eight  from  the  nostrils, 
and  in  sixteen  it  was  expectorated.  Pulmonary  phthisis  was, 
however,  usuall}^  present  in  these  last  cases.  In  the  Western 
Journal  of  3Iedicine  for  1829,  an  interesting  case  is  related  by  Dr. 
Wm.  M.  Voris  of  a  girl,  nine  years  old,  in  whom  hemorrhage 
occurred  under  the  scalp,  producing  great  tumefaction,  and  nearly 
closing  the  ej'^elids.  An  incision  was  made,  from  which  a  pint  and 
a  half  of  dark  blood  escaped,  and  it  was  estimated  that  more  than 
half  a  gallon  was  lost  during  the  ensuing  two  weeks,  at  the  expi- 
ration of  which  time  the  incision  closed.  The  patient  recovered 
from  the  hemorrhage  but  not  from  the  cyanosis. 

Towards  the  close  of  life  there  is  occasionally  more  or  less 
anasarca,  especially  around  the  ankles,  sometimes  in  the  eyelids 
and  face,  and  rarely  to  a  certain  extent  over  the  whole  body.  In 
certain  patients  it  coexists  with  effusion  in  the  serous  cavities.    . 

It  is  evident  that  one  who  is  afiiected  with  the  severer  form  of 
cyanosis  is  disqualified  for  the  duties  of  active  life.  The  sports  of 
childhood  and  the  useful  labors  of  mature  years  require  an  exer- 
tion for  which  he  is  physically  unfit.  He  has  not  the  ability  even 
to  engage  in  animated  conversation,  for  he  is  overcome  by  emotions, 
whether  of  joy  or  sorrow.  He  lives  almost  an  idle  spectator  of 
the  world  around  him,  prevented  by  his  infirmity  from  engaging 
in  its  pursuits. 

Intercurrent  diseases,  especially  those  of  childhood,  are  badly 
tolerated ;  but  hooping-cough  is  the  one  wdiich  these  patients  are 
especially  ill-fitted  to  endure.  Still,  they  sometimes  pass  safely, 
not  only  through  hooping-cough,  but  through  some  of  the  most 
dangerous  febrile  diseases.  It  is  a  question  of  interest,  but  about 
which  little  is  known  with  certainty,  whether  these  intercurrent 
affections  are  influenced  by  the  cyanotic  or  venous  condition  of 
the  blood.     The  symptoms  of  these  affections  are  no  doubt  more 


6S6  CYANOSIS. 

alarming,  iiiainly  on  account  of  the  embarrassed  action  of  the 
heart,  and  not  on  account  of  the  state  of  the  blood ;  still  it  is 
reasonable  to  suppose  that  malignant  and  asthenic  diseases  are 
rendered  worse  by  the  lack  of  oxygen,  and  excess  of  carbonic  acid 
in  the  circulating  fluid. 

Probably  cyanosis  does  not  furnish  immunity  from  any  other 
disease,  although  this  statement  has  been  made  by  a  high  authority. 
Rokitansky  says:  '■'■All  forms  of  cyanosis^  or  rather  all  the  diseases  of 
the  heart,  great  vessels,  and  lungs  adapted  to  produce  cyanosis,  in  a 
greater  or  less  degree,  cannot  coexist  with  tuberculosis.  '  Cyanosis  affords 
a  complete  protection  against  it,  and  in  this  circumstance  may  he  found 
an  explanation  of  the  immunity  from  iuherculosis  which  many  condi- 
tions of  the  system,  apparently  very  different  in  their  character,  afford." 
[Handb.  der  Pathol.  Anat.,  II.  Bd.)  This  opinion  of  the  distin- 
guished pathologist,  notwithstanding  his  ample  opportunities  for 
observation  and  known  accuracy  as  an  observer,  is  not  substan- 
tiated by  statistics.  So  far  from  its  being  true,  the  low  degree  of 
vitality  in  cyanosis  appears  to  favor  tubercular  deposition.  I  have 
records  of  twenty-six  cases  of  cyanosis  in  which  tuberculosis  was 
also  present,  in  several  of  which  the  lungs  contained  cavities. 
This  is  about  thirteen  per  cent,  of  the  whole  number  in  my  collec- 
tion— a  large  proportion,  since  so  many  die  in  early  infancy,  at 
which  period  the  tubercular  disease  is  not  apt  to  occur.  Cyanosis 
appears,  also,  to  favor  the  development  of  cerebral  diseases,  espe- 
cially congestion  and  coma,  as  will  be  seen  presently. 

Prognosis. — This  is  unfavorable.  Most  cyanotic  individuals  die 
young.  The  age  which  they  attain  has  been  made  the  subject  of 
statistical  inquiry  by  Aberle.  He  states  that  in  an  aggregate  of 
159  cases,  57,  or  35  per  cent.,  died  before  the  end  of  the  first  year; 
108,  or  more  than  two-thirds,  died  before  the  age  of  eleven  years; 
30  between  the  ages  of  11  and  25  years ;  and  of  the  remaining  21, 
five  only  lived  more  than  45  years. 

The  age  at  which  death  occurred  is  given  in  186  of  the  cases 
collected  by  myself,  as  follows : — 

In  17  under  the  age  of  1  week.  In  21  from  5  years  to  10  years. 

"  10  from  1  week  to  1  month.  "  41     "     10     "     "  20      " 

"  12     "     1  month  to  3  months.  "  20     "     20     "'    "  40      " 

"11     "     3  months  to  6  months.  "     4  over  40     " 

"  17     "     6      "      to  12       "  

"12     "     1  year  to  2  years.  186 

"  21     "     2  years  to  5    " 

Sixty-seven,  then,  or  more  than  one-third,  died  before  the  close 


MODE    OF    DEATn,  687 

of  the  Arst  year;  121,  or  more  tlian  thrce-fiftlis,  before  the  age  of 
ten  years;  only  24  survived  the  age  of  twenty  years,  and  four  the 
age  of  forty  years.  Of  course,  tlie  duration  of  life  depends  on  the 
nature  and  extent  of  the  malformations.  Some  of  these  are  such 
as  render  a  speedy  death  inevitable. 

Mode  of  Death. — The  mode  of  death  is  recorded  in  ninety-five 
cases,  as  follows: — 

19  died  in  a  paroxysm  of  dyspnoea. 

10     "     suddenly  (the  exact  manner  not  stated). 

14     "     in  convulsions  (infants). 

2     "     of  apoplexy. 

7     "     from  hemorrhage. 

6     "     of  phthisis  (though,  as  we  have  seen,  twenty  others  had 
this  disease). 

2     "     of  exhaustion,  without  hemorrhage. 
10     "     of  coma. 

2     "     of  abscesses  in  the  brain. 

1  "  of  each  of  the  following  diseases:  cerebral  irritation, 
congestion  of  brain,  effusion  in  the  cranial  cavity,  acute  hydro- 
cephalus, paralysis  from  acute  softening  of  the  brain,  dysentery, 
inflammation  of  heart,  syncope,  mucus  in  the  air-passages,  thoracic 
inflammation,  choleraic  diarrhcea,  pneumonitis,  bronchitis,  scarlet 
fever,  croup.  One  died  in  trying  to  walk,  one  after  a  spasmodic 
cough  in  pertussis,  one  after  a  long  agony,  one  after  an  agony  of 
ten  or  eleven  hours;  one  is  recorded  to  have  died  gradually,  and 
three  quietly. 

The  ten  wdio  are  stated  to  have  died  suddenly,  probably  died  in 
paroxysms  of  palpitation  and  dyspnoea,  which,  we  have  seen,  are 
easily  excited,  and  of  common  occurrence  in  cyanosis.  If  so,  this 
was  the  mode  of  death  in  29  cases.  Infants,  with  few  exceptions^ 
so  far  as  appears  from  the  records,  died  in  convulsions.  ISTineteen 
died  of  cerebral  affections,  exclusive  of  convulsions,  and  in  thirteen 
of  these  the  cause  of  death  was  congestion,  apoplexy,  or  coma. 
The  hemorrhage  of  which  seven  died  was  probably,  in  most 
instances,  dependent  on  phthisis,  and  six  are  said  to  have  died 
directly  of  phthisis.  We  may,  then,  regard  paroxysms  of  palpita- 
tion and  dyspnoea,  convulsions,  congestive  affections  of  the  brain,, 
and  phthisis,  as  common  modes  or  causes  of  death  in  cyanosis. 

The  malformations  of  the  heart  and  great  vessels  which  give 
rise  to  cyanosis  are  quite  numerous.  The  following  table  exhibits, 
their  character  and  relative  frequency : — 


688  CYANOSIS. 

CASES' 

1.  Pulmonary  artery  absent,  rudimentary,  impervious,  or  partially  obstructed    97 

2.  Right  auriculo-ventricular  orifice  impervious  or  contracted         ...       5 

3.  Orifice  of  the  pulmonary  artery,  and  the  right  auriculo-ventricular  aper- 

ture, impervious  or  contracted 6 

4.  Right  ventricle  divided  into  two  cavities  by  a  supernumerary  septum        .  11 

5.  One  auricle  and  one  ventricle 12 

6.  Two  auricles  and  one  ventricle 4 

7.  A  single  auriculo-ventricular  opening:    inter-auricular  and  intei'-ventri- 

cular  septa  incomplete 1 

8.  Mitral  orifice  closed  or  contracted 3 

9.  Aorta  absent,  rudimentary,  impervious,  or  partially  obstructed  .        .       3 

10.  Aortic  and  the  left  auriculo-ventricular  orifices  impervious  or  contracted  .  1 

11.  Aorta  and  pulmonary  artery  transposed 14 

12.  The  caviB  entering  the  left  auricle 1 

13.  Pulmonary  veins  opening  into  the  right  auricle  or  into  the  cavse  or  azygos 

veins 2 

14.  Aorta  impervious  or  contracted  above  its  point  of  union  with  the  ductus 

arteriosus  ;  pulmonary  artery  wholly  or  in  part  suppljang  blood  to  the 
descending  aorta  through  the  ductus  arteriosus 2 

Total 164 

From  the  above  table  it  appears  that  in  more  than  one-half  of 
the  cases  of  cyanosis,  the  congenital  vice  which  gives  rise  to  it 
is  located  in  the  pulmonary  artery.  It  is  located  also,  in  general, 
in  that  part  of  the  artery  which  is  nearest  the  heart.  Its  character 
is  different  in  different  cases.  Sometimes  there  is  an  arrested 
development  of  this  vessel,  and  in  its  place  we  find  simply  a 
ligamentous  cord  extending  from  the  heart  as  far  as  the  ductus 
arteriosus,  while  beyond  this  point  the  artery  and  its  branches 
are  pervious  ;  rarely  the  entire  artery  is  ligamentous  and,  of  course, 
impervious ;  in  other  cases  this  vessel  is  open  through  its  whole 
extent,  but  the  part  nearest  the  heart  is  so  small  as  to  be  properly 
considered  rudimentary ;  in  others  still  there  is  adhesion  of  the 
valves  to  each  other  as  the  chief  congenital  defect,  and,  finally,  in 
rare  instances  the  obstruction  in  the  jjulmonary  artery  is  due  to  an 
adventitious  membrane,  which  stretches  across  the  vessel  like  a 
diaphragm.  These  last  malformations,  namely,  adhesion  of  the 
valves  and  the  formation  of  an  adventitious  membrane,  are,  doubt- 
less, due  to  inflammation  occurring  in  the  artery  before  birth,  and 
6ome  attribute  the  arrested  development  and  ligamentous  state  of 
the  vessel  to  the  same  cause. 

In  most  cases  of  cvanosis  due  to  obstructive  malformations, 
there  is  deficiency  in  the  inter-auricular  and  inter- ventricular  seiDta. 
This  deficiency  obviously  results  from  the  obstruction,  for  the  septa 
are  formed  in  the  heart,  after  foetal  circulation  is  established,  and 


MORBID    ANATOMY.  689 

the  blood,  being  prevented  by  the  vicious  formation  from  flowing 
in  its  proper  channel,  necessarily  passes  to  the  opposite  side  of  the 
heart.  More  or  less  blood  being  forced  from  one  auricle  or  pne 
ventricle  to  the  opposite  cavity,  it  is  evident  that  a  permanent  aper- 
ture must  result  in  the  septum.  The  aperture  in  the  septum  ven- 
triculorum  is  ordinarily  at  its  base ;  in  the  septum  auriculorum,  it 
corresponds  with  the  foramen  ovale. 

In  most  of  the  obstructive  malformations  one  and  rarely  two 
abnormal  cardiac  murmurs  have  been  observed.  The  single  mur- 
mur accompanies  the  ventricular  contraction.  As  it  has  been  ob- 
served in  cases  of  complete  as  well  as  incomplete  obstruction,  it 
seems  to  be  due  mainly  to  the  flow  of  blood  through  the  apertures 
in  the  septa. 

Modes  of  Compensation. — In  most  cases  of  cyanosis,  the  con- 
genital defect  is  partially  obviated  by  modes  of  compensation. 
In  the  most  frequent  malformation,  that  in  which  there  is  obstruc- 
tion in  the  pulmonary  artery,  and  a  considerable  part  if  not  all 
the  blood  flows  directly  from  the  right  to  the  left  side  of  the  heart, 
the  ductus  arteriosus  not  only  remains  open,  but  is  greatly  en- 
larged, through  which  a  current  of  blood  enters  the  pulmonary 
artery  from  the  aorta,  and  passing  to  the  lungs  is  oxygenated. 
The  bronchial  arteries  have  also  been  found  greatly  enlarged,  and 
it  is  believed  that  though  they  are  the  nutrient  arteries  of  the 
lungs,  the  blood  which  they  convey  to  these  organs  is  decarbonized 
in  its  circuit  through  them.  In  a  case  published  by  Mr.  Le  Gros 
Clark,  in  the  31edico-Chir.  Trans. ^  vol.  xxx.,  the  bronchial  arteries 
were  not  only  enlarged,  but  a  "branch  from  the  internal  mammary 
artery,  which  accompanied  the  phrenic  nerve,  was  nearly  equal  in 
size  to  the  parent  trunk,  and  expended  itself  principally  in  the  ad- 
jacent adherent  lung."  Branches  of  the  intercostal  arteries  have 
also  been  found  enlarged,  and  entering  the  lungs,  or  connecting 
with  vessels  which  entered  the  lungs.  By  such  modes  of  compen- 
sation cyanosis  is  rendered  milder,  and  life  is  prolonged.  To  these 
we  must  attribute  the  fact  that  some  have  very  considerable  mal- 
formation, and  yet  do  not  become  cyanotic. 

Morbid  Anatomy. — This,  as  regards  the  circulatory  system,  has 
been  sufficiently  dwelt  upon.  iTo  chemical  analysis,  so  far  as  I  am 
aware,  has  yet  been  made  of  cyanotic  blood.  We  know  that  it  is 
dark,  its  coagulability  feeble,  that  it  contains  an  excess.^of  carbonic 
acid,  and  is  deficient  in  oxygen.  From  the  nature  of  cyanosis,  it 
would  be  inferred  that  in  many  cases  there  is  a  degree  of  passive 
congestion  in  the  cavities  of  the  heart,  and  consequently  in  the 
44 


690  CYANOSIS. 

capillaries  of  the  systemic  system,  giving  rise  to  more  or  less  serous 
effusion.  Statistics  show  that  this  is  so.  The  quantity  of  pericar- 
dial fluid  is  in  some  patients  increased.  I  have  records  relating  to 
this  fluid  in  fifty-one  cases.  Usually  it  was  pure  serum.  In  seven- 
teen the  quantity  was  half  an  ounce  or  less,  if  we  include  in  the 
number  those  in  which  the  amount  is  expressed  in  such  terms  as 
"  due  quantity,"  "  unusual  amount,"  and  "  small  amount."  In 
twenty-four  cases  the  serum  exceeded  half  an  ounce  ;  usually  esti- 
mated at  from  one  to  six  ounces,  but  in  two  it  exceeded  the  latter 
quantity.  In  one  of  the  twenty-four  the  serum  was  sanguinolent. 
In  two  cases  the  records  state  that  there  was  a  small  quantity  of 
blood  in  the  pericardium,  and  in  the  remaining  patient  the  two 
pericardial  surfaces  were  agglutinated  by  inflammation. 

In  some  of  the  autopies  serous  eff"usion  was  found  in  the  pleural 
cavities,  usually  in  connection  with  pericardial  effusion,  and  in  at 
least  one  instance  the  serum  was  tinged  with  blood.  Old  adhe- 
sions between  the  costal  and  pulmonary  pleura  were  observed  in 
a  few  instances.  The  condition  of  the  lungs  was  recorded  with 
more  or  less  minuteness  in  one  hundred  and  ten  cases.  Mention 
has  already  been  made  of  the  large  number  affected  with  tuber- 
cular disease,  which  was  either  confined  to  the  lungs,  or  was  chiefly 
exhibited  in  these  organs.  In  thirty-five  patients  the  records  state 
that  the  lungs  were  of  small  size,  either  by  compression,  or  some- 
times, apparently,  by  the  continuance  of  the  foetal  state  over  a 
greater  or  less  portion  of  the  organ.  The  compression  was  produced 
either  by  the  distended  pericardium  or  by  effusion  in  the  pleural 
cavities.  In  thirty-five  cases  the  lungs  presented  a  dark  color. 
This  hue  in  some  si:)ecimens  accompanied  the  unexpanded  or  foetal 
state  of  the  organ,  but  in  others  there  was  the  normal  inflation,  and 
the  dark  color  was  due  to  engorgement  or  congestion.  In  other 
cases  the  lungs  are  stated  to  have  been  natural,  except  the  color. 
In  nine  there  was  emphysema  in  a  part  of  the  lungs,  in  two  pneu- 
monitis ;  in  two  the  color  was  pale,  in  one  a  bright  crimson ;  in  one 
the  lungs  were  larger  than  natural,  in  one  the  right  lung  was  ab- 
sent, and  in  seventeen  these  organs  were  recorded  healthy. 

I  have  records  of  the  state  of  the  liver  in  twenty-six  cases,  in 
sixteen  of  which  it  was  enlarged,  and  in  four  of  those  enlarged  it 
was  congested.  Congestion  was  present  in  eight  other  cases,  in 
Avhich  no  ijiention  is  made  of  the  volume.  The  parenchyma  had  a 
natural  appearance  in  nine  cases,  but  in  some  of  these  there  was 
enlargement.  From  these  statistics  it  is  probable  that  the  liver  is 
commonly  enlarged  in  cyanosis,  and  not  infrequently  congested. 


THEORIES    RELATING    TO    ETIOLOGY    OF    CYANOSIS.      691 

In  a  few  cases  the  condition  of  the  other  abdominal  viscera  is 
mentioned ;  in  some  as  healthy,  in  others  as  congested.  There 
were  fifteen  examinations  of  the  brain,  in  seven  of  which  conges- 
tion is  recorded,  and  in  three  abscesses  in  the  cerebral  substances, 
in  one  of  which  cases  the  lateral  ventricle  was  also  filled  with 
pus;  in  two  there  was  softening  of  a  portion  of  the  brain,  in  three 
the  brain  was  firm  or  compact,  in  three  the  quantity  of  fluid  in 
•  the  cranial  cavity  exceeded  the  normal  amount,  and  in  one  it  was 
less. 

Theories  Relating  to  the  Etiology  of  Cyanosis. — Although  in 
nearly  all  cyanotic  patients  there  are  direct  communications  between 
the  two  sides  of  the  heart,  it  is  shown  by  many  observations  that 
these  communications  or  apertures  are  not  sufficient  in  themselves 
to  produce  cyanosis.  This  opinion  was  expressed  half  a  century 
ago  by  Louis,  who  published  an  excellent  monograph  on  the  sub- 
ject of  these  communications,  basing  his  remarks  on  an  analysis  of 
twenty  cases.  Since  the  publication  of  his  paper,  the  belief  has 
been  pretty  general  in  the  profession,  and  observations  continue  to 
substantiate  it,  that,  although  the  apertures  may  be  of  considerable 
size,  if  the  two  sides  of  the  heart,  with  their  orifices  and  vessels, 
are  in  their  normal  state,  so  that  they  act  symmetrically  and 
without  obstruction,  cyanosis  will  not  occur.  In  j)roof  of  the  cor- 
rectness of  this  opinion  many  cases  might  be  cited  of  a  pervious, 
and  some  of  a  largely  dilated  foramen  ovale  without  the  cyanotic 
hue,  cases  which  have  been  published  in  the  journals  since  the 
appearance  of  Louis's  monograph.  Still,  in  cases  of  obstructive 
malformation,  unless  the  obstruction  is  complete,  cyanosis  is  more 
apt  to  occur  in  cons^uence  of  these  apertures,  for  were  they  absent 
a  larger  amount  of  blood  would  be  propelled  through  the  narrowed 
orifice,  and  a  larger  amount  consequently  be  oxygenated. 

Allusion  has  already  been  made  to  the  two  theories  which  pre- 
vail in  the  profession ;  the  one  attributing  cyanosis  to  the  inter- 
mingling of  venous  and  arterial  blood  ;  the  other  to  obstruction 
at  the  centre  of  circulation,  and  consequent  venous  congestion. 
There  are  serious  objections  to  the  acceptance  of  either  theory  as 
an  explanation  for  all  cases.  That  admixture  of  the  two  kinds  of 
blood  is  not  essential  to  the  production  of  cyanosis,  is  apparent 
from  the  following  facts.  In  one  case  in  the  Fourth  Mdformation, 
there  was  no  communication  between  the  two  sides  of  the  heart, 
and  the  ductus  arteriosus  was  closed,  so  that  admixture  was  impos- 
sible. Again,  in  the  Eleventh  Malformation^  or  that  in  which  the 
aorta  and  pulmonary  artery  are  transposed,  the  blue  disease  evi- 


692  CYANOSIS. 

dently  does  not  depend  on  the  admixture  of  the  two  currents.  On 
the  other  hand,  in  this  curious  state  of  the  heart,  the  more  the 
admixture  the  less  the  cyanosis,  since  the  only  way  in  which  the 
systemic  current  of  blood  can  be  arterialized  is  by  passing  to  the 
opposite  side  of  the  heart.  An  argument  against  this  doctrine 
may  also  be  found  in  the  fact  that  the  modes  of  compensation  are 
not  such  as  in  any  way  diminish  or  obviate  the  admixture.  It  is 
admitted  that  in  the  more  frequent  malformations  cyanosis  is  in- 
creased by  the  apertures,  which  allow  the  intermingling  of  the 
venous  and  arterial  currents,  but  it  is  more  reasonable  to  consider 
the  intermingling  and  the  cyanosis  as  the  direct  results  of  the  mal- 
formation, neither  having  the  precedence  of  the  other,  than  to 
consider  that  they  are  related  to  each  other  as  cause  and  eiFect,  or 
as  proximate  and  remote  results.  Viewed  in  this  light,  the  admix- 
ture must  be  considered  simply  a  concomitant  of  the  cyanosis. 

The  second  theory,  that  of  venous  congestion,  has  numbered 
among  its  advocates  many  who  have  given  special  attention  to  the 
subject,  as  Morgagni,  Louis,  and  Stille,  but  it  seems  to  have  even 
less  claim  for  acceptance  than  the  theory  of  admixture.  It  has 
been  seen  that  in  nearly  all  cases  of  cyanosis  the  two  sides  of  the 
heart  communicate  freely,  so  that  if  the  current  of  blood  meets 
with  an  obstruction,  as  it  commonly  does,  it  readily  escapes  to  the 
opposite  side  where  the  artery  is  large  and  gives  it  free  passage. 
In  this  way  congestion,  if  not  prevented,  is  greatly  diminished. 
Again,  it  will  be  seen  that,  although  certain  of  the  viscera  are 
frequently  found  at  the  autopsy  more  or  less  congested,  congestion 
is  not  uniformly  present  in  the  organs,  as  it  would  probably  be 
were  it  the  proximate  cause  in  all  cases  of  cyanosis. 

Moreover,  in  some  patients  the  malformation  is  not  obstructive. 
The  cavities  and  their  orifices  are  of  the  normal  size,  and  cyanosis 
is  due  entirely  to  malposition  of  the  vessels.  It  cannot  be  said 
that  in  these  cases  there  is  venous  congestion  from  arrest  at  the 
centre  of  circulation.  If  there  is  any  congestion,  it  must  be  due 
to  the  fact  that  venous  blood  does  not  circulate  as  readily  as  the 
arterial  in  the  capillaries.  It  is  true  that  in  the  paroxysms  of 
dyspnoea  there  is  sometimes  more  or  less  congestion;  the  disten- 
sion of  the  jugulars  shows  this,  but  it  subsides  with  the  paroxysms, 
and  is  probably  no  more  than  usually  occurs  when  the  respiration 
is  greatly  embarrassed. 

In  fine,  attempts  to  express  the  immediate  pathological  state 
producing  cyanosis  in  the  terms  of  a  general  law  have  failed. 
However  plausible  the  above  theories  may  appear  in  regard  to 


TREATMENT.  693 

certain  cases,  there  are  others  to  which  they  are  manifestly  inap- 
pliciible.  Those  wlio  advocate  these  theories  seem  to  lose  sight  of 
the  obvious  fact  that  the  chief  want  of  the  economy  in  cyanosis  is 
arterialization  of  the  blood,  and  it  is  hardly  supposable  that  there 
can  be  any  correct  theory  of  its  causation  which  is  not  founded  on 
this  fact.  With  this  want  of  the  economy  in  view  it  does  not 
seem  difficult  to  express  a  theory  in  comprehensive  terms  which  is 
applicable  to  all  cases,  such  as  the  following:  Cyanosis  is  due  to 
vices  or  defects  in  the  organism^  usually  congenital^  which  pxvent  the 
free  and  regular  flow  of  blood  to,  through,  or  from  the  lungs.  So  com- 
prehensive a  statement  includes  not  only  cases  of  malformation 
and  malposition  of  the  heart  and  its  vessels,  but  also  those  few 
cases  in  which  the  lungs  are  in  fault.  In  most  patients,  as  we 
have  seen,  the  current  of  blood  towards  the  lungs  is  obstructed,  and 
the  current  of  blood  from  the  lungs,  in  those  comparatively  rare 
cases  in  which  the  malformation  is  on  the  left  side. 

Treatment. — From  the  nature  of  cyanosis,  it  is  evident  that 
the  treatment  should  be  more  hygienic  than  medicinal.  The  patient 
should  be  warmly  clad  and  kept  in  a  warm  room,  and  all  agencies 
calculated  to*  embarrass  or  disturb  the  functions  of  the  body  or 
excite  the  emotions,  and  thereby  accelerate  the  action  of  heart, 
should  be  studiously  avoided.  The  diet  should  be  nutritious,  but 
simple  and  easily  digested. 

Those  who  have  attributed  cyanosis  wholly  to  apertures  in  the 
inter-auricular  and  inter-ventricular  septa,  and  the  consequent  flow 
of  blood  from  the  right  to  the  left  side  of  the  heart,  have  considered 
it  an  important  part  of  the  treatment  to  keep  the  patient  reclining 
on  the  right  side,  so  as  to  diminish  this  flow  by  the  efiect  of  gravi- 
tation. The  reader,  however,  must  be  convinced  from  the  nature 
of  the  malformations  that  little  benefit  can  accrue  from  following 
such  advice.  Still,  patients  are  sometimes  less  cyanotic  and  more 
comfortable  in  one  position  than  another.  In  a  case  reported  by 
Mr.  Ilowship  {Mlin.  lied.  Journ.,  1813)  "the  only  easy  and  indeed 
comfortable  position  in  which  the  child  could  remain  was  that 
usual  in  nursing.  "When  erect,  the  dusky  color  of  the  face  and 
neck  became  a  dark  blue."  In  a  case  related  b}^  Mr.  Spackman 
(Lond.  31ed.  (raz.,1833),  the  patient  was  easiest  on  the  hands  and 
knees.  Louis  reports  a  case  {de  la  Commun.  des  Cav.,  etc.)  in  which 
the  selected  position  was  with  the  head  elevated;  Wm.  Hunter 
a  case  {Med.  Ohs.  and  Enq.,  vol.  vi.)  in  which  the  patient  avoided 
paroxysms  by  lying  on  the  left  side.  Struthers  and  King  each 
reports  a  case  in  which  the  patients  seemed  most  comfortable  while 


694  CYANOSIS. 

lying  on  the  right  side  {Monthly  Journ.  of  Med,  Sci.),  while,  on  the 
other  hand,  Prof.  White  of  Buffalo  {Bvf.  Med.  Journ.,  1855),  and 
Dr.  Jas.  Carson  {Amer.  Journ.  of  Med.  Sci.,  1857),  report  cases  in 
which  position  on  the  right  side  failed  to  produce  any  alleviation 
of  symptoms.  Other  similar  observations  might  be  cited,  but 
enough  have  been  mentioned  to  show  that  no  one  position  should 
be  recommended  for  cyanotic  patients.  Some  obtain  most  relief 
by  lying  on  the  back,  others  on  the  right  side,  others  on  the  left, 
some  when  on  the  hands  and  knees,  some  when  reclining  on  either 
side  indifferently,  while,  finally,  others  suffer  least  when  erect. 

There  was  a  time  when  the  paroxysms  were  treated  by  vene- 
section, but  depletion  has  long  since  been  abandoned.  Physicians 
now  rely  on  stimulants,  antispasmodics,  friction  to  the  chest,  and 
mustard  pediluvia  to  relieve  the  urgent  symptoms,  although  this 
treatment  is  but  partially  successful. 


SECTIOIsr  Y. 

SKIN  DISEASES. 

CHAPTER    I. 

ERYTHEMATOUS  DISEASES. 

Under  this  head  are  included  erythema,  roseola,  and  urticaria. 
They  consist  in  an  active  congestion,  inflammatory  it  is  believed, 
of  the  skin,  which  soon  declines,  with  or  without  slight  furfura- 
ceous  desquamation.  The  color  of  the  aifected  cuticle  is  a  bright 
red  in  erythema,  rosy  in  roseola,  and  a  pale  red  in  urticaria. 
Febrile  symptoms  often  precede  for  a  few  hours  the  occurrence  of 
the  eruption,  and  abate  as  it  appears. 

Erythema. 

The  eruption  of  erythema  occurs  in  patches  of  different  sizes,  the 
largest  ordinarily  not  exceeding  four  or  five  inches  in  length  and 
most  of  them  have  considerably  smaller  dimensions,  their  margins 
being  in  some  instances  diffused,  and  in  others  circumscribed  and 
well  defined.  The  patches  are  slightly  swollen  from  engorgement 
of  the  capillaries  of  the  skin  and  slight  serous  effusion,  and  are 
accompanied  by  a  sensation  of  heat  and  itching. 

Erythema  is  idiopathic  or  symptomatic.  The  idiopathic  form  is 
subdivided  into  erythema  simplex,  intertrigo,  and  leeve.  Erythema 
simplex  is  produced  by  external  agencies  of  an  irritating  nature, 
as  heat,  cold,  friction,  chemical  and  mechanical  irritants,  applied  to 
the  skin.  A  common  example  of  this  form  of  the  disease  is  the 
eflQorescence  about  the  anus  in  cases  of  infantile  diarrhoea  due  to 
acidity  of  the  evacuations.  Erythema  intertrigo  is  produced  by 
the  friction  of  opposing  surfaces  of  the  skin,  and  it  therefore  occurs 
mainly  in  the  folds  of  the  neck,  about  the  groins,  and  behind  the 
ears.  This  inflammation  is  sometimes  slight,  disappearing  in  two 
or  three  days  with  proper  treatment ;  in  other  cases  the  epidermis 
becomes  denuded,  the  surface  is  tender  and  moist,  and  even  super- 


6dQ  ERYTHEMA. 

ficial  excoriations  occur.  In  severe  cases  the  ulcers  extend  more 
deeply,  and  give  rise  to  considerable  purulent  discharge,  the  skin 
and  even  subcutaneous  connective  tissue,  being  more  or  less 
infiltrated  and  indurated.  The  confinement  of  the  perspiration, 
and  the  moisture,  which  is  exuded  between  the  folds  of  the  skin, 
increase  the  inflammation.  The  effused  liquid  does  not  in  ordinary 
cases  stiffen  linen,  as  in  eczema.  Erythema  Iseve  is  the  name 
applied  to  the  inflammatory  hyperemia  of  the  skin,  which  often 
occurs  over  oedematous  parts.  Its  most  common  seat  is  about  the 
ankles  and  upon  the  legs.  In  children  it  is  most  frequently 
observed  in  the  oedema  which  results  from  scarlatinous  nephritis 
and  from  heart  disease. 

Symptomatic  erythema,  which  results  from  a  general  or  constitu- 
tional cause  of  a  pyrexial  character,  has  several  subdivisions.     The 
simplest  and  mildest  form  of  it  is  erythema  fugax,  which  comes 
and  goes  quickly.     The  erythema  which  occurs  upon  the  features 
in  acute  meningitis  is  a  typical  example.     It  is  common  in  various 
inflammatory  and  febrile  affections.     If  the  erythematous  patch  is 
circular,  with  normal  skin  in  its  centre,  it  is  sometimes  designated 
erythema  circinatum,  and  if  the  margin  is  well  defined,  margi- 
natum.     Erythema  papulatum,  tuberculatum,  and  nodosum  are 
applied  to  the  same  form  of  the  disease,  one  or  the  other  term 
being  employed  according  to  the  stage  or  size  of  the  eruption.     lu 
erythema  papulatum  the  eruption  begins  as  small  red  spots,  which 
soon  become  papular,  and  attain  a  size  varying  from  that  of  a  pin's 
head  to  a  split  pea.     It  occurs  especially  on  the  neck,  breast,  arm, 
and  back  of  the  hand,  and  fades  away,  with  a  slight  desquamation, 
in  about  three  weeks.     In  erythema  tuberculatum  and  nodosum 
the  eruptions  have  a  greater  diameter,  and  are  usually  more  promi- 
nent.    In  the  latter  variety  they  often  have  a  diameter  of  two  or 
more  inches,  and  occur  most  frequently  upon  the  anterior  aspect 
of  the  leg.      These  three  forms  of  erythema,  which   might   be 
described  as  one,  occur  chiefly  in  young  people.     Erythema  tuber- 
culatum is  most  common  in  servants,  especially  those  recently  from 
the  country.     The  tumefaction  is  due  to  the  effusion  of  serum  in 
the  corium,  and,  when  the  eruption  has  considerable  prominence, 
also  in  the  subcutaneous  connective  tissue.     The  color  is  at  first  a 
bright  red,  then  dark  red  or  purjDle,  and  it  fades  away  like  the 
discoloration  of  a  bruise  as  the  eruption  declines.     Rheumatism 
is  often  and  diarrhoea  occasionally  associated  with  these  forms  of 
erythema,  and  rheumatic  pains  are  occasionally  present,  as  well  as 
more  or  less  febrile  movement. 


TREATMENT.  697 

Prognosis. — This  as  regards  the  erythema  is  always  good.  An 
unfavorable  result  in  any  case  is  due  to  cachexia,  or  some  coexist- 
ing disease.  The  duration  of  the  milder  forms  is  only  a  few  hours, 
while  the  severer  forms,  as  erythema  nodosum,  last  two  or  three 
weeks. 

Diagnosis. — The  ordinary  forms  of  erythema  are  distinguished 
from  erysipelas^  by  the  absence  of  any  very  decided  burning  pain, 
and  tumefaction  of  the  integument,  and  tendency  to  spread,  and 
by  less  marked  constitutional  symptoms.  In  those  forms  of 
erythema  in  which  there  is  infiltration  and  swelling  of  the  skin 
and  subcutaneous  connective  tissue,  the  patches  are  distinguished 
from  those  of  erysipelas  by  being  multiple,  of  smaller  size,  less  hot 
and  painful,  not  extending,  and  presenting  as  they  disappear  the 
phenomena  of  a  bruise.  In  urticaria  the  wheals  that  come  and  go 
suddenly  with  a  peculiar  stinging  sensation,  and  the  irritability  of 
the  skin  by  which  these  wheals  can  be  produced  by  slight  friction, 
diifer  in  so  marked  a  degree  from  the  symptoms  and  appearances 
of  erythema  that  the  difiJerential  diagnosis  of  the  two  is  easy.  In 
roseola  the  eruption  ordinarily  occurs  over  a  large  part,  if  not  the 
entire  surface,  in  points  and  small  patches  with  healthy  skin 
between,  and  presenting  a  rosy  instead  of  a  bright-red  color, 
characters  which  sufficiently  distinguish  it  from  erythema.  Ery- 
thema when  extensive  is  sometimes  mistaken  for  the  scarlatinous 
eruption,  but  the  redness  of  the  fauces,  graver  constitutional 
symptoms,  vomiting,  persistence  of  the  eruption,  etc.,  serve  to 
distinguish  the  latter  from  the  former  aflrection.  In  cases  of  doubt 
it  is  proper  to  defer  the  diagnosis  for  a  day  or  two,  when  if  the 
rash  is  erythematous  it  will  fade.  Erythema  sometimes  occurs  in 
the  initial  stage  of  variola,  when  on  account  of  the  grave  general 
symptoms  it  may  be  mistaken  for  scarlatina.  I  have  more  than 
once  known  this  mistake  to  be  made  in  the  hurried  visit  of  the 
physician.  A  more  careful  examination  would  prevent  this  error. 
There  is  little  danger  of  confounding  erythema  with  measles,  or 
the  various  papular,  vesicular,  or  pustular  skin  diseases. 

Treatment. — Erythema  fugax  requires  no  special  treatment, 
unless  occasional  dusting  the  surface  with  lycopodium  or  powdered 
starch.  Those  forms  of  erythema  which  are  due  to  a  mechanical 
or  chemical  irritant  soon  disappear  when  the  cause  is  removed. 
In  erythema  around  the  anus,  produced  by  the  irritation  of  the 
urinary  and  alvine  evacuations,  the  diaper  should  be  changed  as 
soon  as  soiled,  and  if  the  stools  are  frequent  and  acid,  the  alkaline 
treatment  proper  for  the  diarrhosa  is  useful  also  for  the  erythema. 


698 


EOSEOLA. 


In  inflammation  from  this  cause  as  well  as  in  erythema  intertrigo, 
the  following  prescriptions  will  be  found  beneficial : — 

R,  Pulv.  zinci  oxid., 

Lycopodii,  aa.  equal  parts.     Misce. 
To  be  frequently  dusted  upon  inflamed  surface. 

R.  Zinci  oxid.  5ij ; 
Glycerinse  5ij  ; 
Liq.  plumb,  subacetatis  3jss; 
Aquae  calcis  ^vj  to  viij-.     Misce. 

In  obstinate  cases  a  weak  solution  of  nitrate  of  silver,  sulphate 
of  copper,  or,  better,  as  it  does  not  stain  the  linen,  sulphate  of  zinc, 
will  frequently  be  followed  by  immediate  improvement. 

R.  Zinci  sulphat.  gr.  vj  ; 
Glycerinse  gij ; 
Aq.  rosa3  ^iv.     Misce. 
To  be  constantly  applied  between  the  folds  of  the  skin  on  linen. 

Chlorate  of  potash,  internally,  to  correct  the  acidity  of  the 
transpiration  from  the  skin  in  protracted  and  obstinate  cases,  and 
in  certain  instances  cod-liver  oil  and  the  syrup  of  iodide  of  iron,  are 
called  for.  If  the  derangement  of  the  system,  upon  which  the 
erythema  depends,  appears  to  be  of  a  rheumatic  character,  colchicum 
or  alkalies  may  be  required.  Erj^thema  papulatum,  tuberculatum, 
and  nodosum  occur  most  frequently  in  reduced  states  of  the  system, 
and  therefore  require  tonics. 

Roseola. 

The  term  roseola  is  applied  to  rose-colored  spots  or  patches  ol 
greater  or  less  extent,  accompanied  by  a  degree  of  febrile  reaction, 
and  often  by  redness  with  little  or  no  swelling  of  the  faucial 
surface.  It  is  attended  by  a  sensation  of  warmth  and  slight 
itching.  The  following  groups  and  subdivisions  embrace  the 
recognized  varieties  of  this  disease. 


Roseola. 


Idiopathic. 

Infantilis. 

Estiva. 

Autumnalis. 

Annulata. 

Punctata. 


Symptomatic. 

Variolosa. 

Vaccinia. 

Miliaris. 

Rheumatica. 

Arthritica. 

Cholerica. 

Febris  continuse. 

Syphilitica. 


SYMPTOMS.  699 

The  color  of  the  eruption  gradually  fades  from  a  rose  red  to  a 
duller  hue,  and  often  disappears  in  two  or  three  days.  In  other 
instances  the  eruption  lasts  a  week  or  more.  Roseola  may  occur 
in  any  season,  but  it  is  most  common,  especially  the  idiopathic  form, 
in  the  warm  months.  Those  varieties  of  the  idiopathic  disease 
which  are  designated  infantilis,  cestiva,  and  autumnalis  are  the  most 
common  in  early  life.  They  are  in  reality  indentical,  or  nearly  so, 
and  may  be  described  as  one  disease. 

Symptoms. — Roseola  infantilis,  sestiva,  or  autumnalis  may  be 
partial,  appearing  upon  the  arms  and  legs,  or  general.  It  is  often 
preceded  by  febrile  movement,  languor,  and  in  those  old  enough 
to  describe  their  sensations,  pain  in  head,  back,  and  limbs.  There 
is  great  difference,  however,  in  different  cases  as  regards  the 
severity  of  the  prodromic  symptoms.  They  may  be  absent  or  so 
slight  as  scarcely  to  be  appreciable.  Occasionally  vomiting,  diar- 
rhoea, or  other  symptoms  of  derangement  of  the  digestive  apparatus 
immediately  precede  the  eruption. 

The  eruption  of  roseola,  when  general,  usually  commences  upon 
or  about  the  neck  and  face,  and  in  the  course  of  twenty-four  to 
thirty-six  hours  appears  upon  the  rest  of  the  surface.  It  bears  con- 
siderable resemblance  to  that  of  measles.  The  patches  are  irregu- 
lar in  shape,  a  quarter  to  half  an  inch  in  diameter,  and,  though  of 
a  rose  color  at  first,  they  soon  present  a  dusky  hue  as  they  begin  to 
fade  ;  by  pressure  the  redness  disappears.  In  the  majority  of  cases 
the  eruption  has  nearly  faded  by  the  fifth  day.  The  redness  of  the 
faucial  surface,  together  with  the  itching  or  tingling,  disappears 
with  the  subsidence  of  the  rash. 

Roseola  annulata  is  a  rare  disease.  It  commences  with  constitu- 
tional symptoms,  which  are  slight  or  pretty  severe,  and  which 
cease  when  the  eruption  appears.  This  occurs  in  the  form  of  red 
circular  spots,  which  enlarge  to  the  diameter  of  an  inch  or  there- 
about and  assume  the  shape  of  rings  inclosing  healthy  skin. 
The  rash  fades  in  a  few  days,  often  leaving  a  bruised  appearance. 
The  ordinary  location  of  this  form  of  erythema  is  upon  the  abdo- 
men, and  about  the  thighs.  In  roseola  punctata  the  eruption  is  of 
small  size,  and  it  occurs  upon  a  large  part  of  the  surface. 

Symptomatic  roseola,  which  appears  in  the  course  of  various 
diseases,  need  only  be  alluded  to.  The  diseases  in  which  it  is 
developed  are,  with  the  exception  of  syphilis,  chiefly  of  an  acute 
febrile  or  inflammatory  character.  This  eruption  is  often  really,  as 
stated  by  Tilbury  Fox,  a  rose-colored  erythema,  but  in  other  in- 
stances it  presents  the  typical  form  and  appearance  of  roseola.  Thus 


700  ROSEOLA. 

I  have  known  it  to  occur  about  tlie  eighth  or  ninth  day  of  vaccinia 
in  rose-colored  spots  over  the  whole  surface,  and  producing  much 
anxiety  on  the  part  of  parents,  lest  impure  virus  had  been  em- 
ployed. 

Causes. — These  are  in  a  measure  obscure.  The  delicacy  of  the 
skin  in  infancy  and  the  active  cutaneous  circulation  no  doubt  pre- 
dispose to  roseola  and  erythema,  and  hence  the  frequency  of  their 
occurrence  in  acute  febrile  and  inflammatory  affections.  Summer 
weather,  with  the  derangements  of  system  which  it  produces,  has 
been  in  my  experience  much  the  most  frequent  cause  of  idiopathic 
roseola  in  young  children  in  this  city.  In  certain  summers,  as  in 
that  in  1868,  a  large  proportion  of  the  infants  have  been  affected 
by  it,  and  I  have  been  led  to  consider  it  a  favorable  prognostic  sign 
as  regards  the  diarrhoeal  affections,  which  are  so  common  in  the 
warm  months. 

Prognosis. — Roseola  is  always  a  mild  and  favorable  disease. 
Diagnosis. — Roseola  is  distinguished  from  measles  by  the  absence 
of  catarrhal  symptoms,  the  less  degree  of  fever,  less  uniformity 
in  the  size  of  the  eruption,  and  the  absence  of  any  history  of  con- 
tagion. Roseola  is  distinguished  from  erythema  by  the  smaller 
size  of  the  eruption  and  its  rosy  or  dusky  red  color.  The 
boundary  line,  however,  between  the  two  affections  is  not  well 
defined,  and  certain  forms  of  roseola  might  be  described  as  ery- 
thema. The  general  but  punctiform.efilorescence,  increase  of  tem- 
perature, acceleration  of  pulse,  and  the  peculiar  appearance  of  the 
tongue  and  fauces,  serve  to  distinguish  scarlet  fever  from  roseola. 
There  is  little  danger  of  confounding  roseola  with  urticaria,  since 
the  wheals  of  the  latter  appear  in  no  other  disease. 

Treatment. — This  is  simple.  If  roseola  occur  in  connection  with 
gastro-intestinal  derangement  or  disease,  the  remedies  which  re- 
lieve the  latter  exert  a  curative  effect  upon  the  former.  In  all 
cases  the  state  of  the  system  should  be  inquired  into,  and  any 
departure  from  a  state  of  health  corrected.  Roseola  needs  no 
farther  constitutional  treatment.  If  there  is  itching  or  tingling 
of  the  surface,  a  lukewarm  lotion,  containing  equal  parts  of  liq. 
amnion,  acetat.  and  mistura  camphorj«,  has  been  recommended, 
or  a  lotion  containing  a  drachm  of  hydrocyanic  acid  to  a  pint  of 
an  emulsion  of  bitter  almonds,  used  warm.  The  purpose  of  such 
lotions  is  simply  to  relieve  the  unpleasant  sensation.  Cold  appli- 
cations, or  others  which  would  repel  the  eruption,  should  be 
avoided  ;  such  an  effect  might  be  injurious.     In  cases  of  acidity  of 


URTICARIA.  701 

stomach  alkaline  remedies  are  useful,  and  in    certain  cases  tonic 
treatment  is  indicated. 

Urticaria. 

The  name  by  which  this  disease  is  designated  is  derived  from 
the  term  u?iica,  the  nettle,  the  sting  of  which  produces  this  form 
of  eruption.  The  eruption  occurs  suddenly  in  wheals  or  pomphi, 
attended  by  tingling  and  burning,  and  suddenly  disappearing. 
Urticaria  is  often  accompanied  by  no  very  decided  general  symp- 
toms, but  in  other  cases  there  are  febrile  movement,  and  lassitude, 
with  perhaps  epigastric  pain  and  headache.  The  wheals  may 
occur  over  the  whole  body,  but  more  frequently  are  confined  to 
a  portion  of  it.  Their  shape  may  be  round,  oval,  irregular,  or 
bandlike,  and  their  length  varies  from  a  few  lines  to  several  inches. 
In  one  affected  by  urticaria  the  wheals  can  be  readily  produced  by 
scratching  or  rubbing  the  surface.  The  eruption  is  thus  clearly 
described  by  a  recent  writer:  "At  first  a  bright  flush  appears,  the 
centre  of  this  becomes  slightly  elevated,  and  pales,  hence  appears 
of  lighter  color ;  the  tint  may  be  rosy,  but  more  generally  it  is 
whitish."  The  margin  of  the  wheal,  the  diameter  of  wdiich 
varies,  always  remains  red.  This  eruption  appears  to  be  produced 
by  active  congestion  of  the  cutaneous  capillaries,  some  serous 
effusion,  and  spasm  of  the  muscular  fibres  of  the  skin.  The 
efi"usion  of  serum  in  certain  localities  is  quite  apparent  from  the 
oedema  which  occurs.  The  subsidence  of  the  eruption  is  without 
desquamation.  Urticaria  is  ordinarily  an  acute  disease.  It  is 
sometimes  chronic  in  the  adult,  but  rarely  so  in  children.  Several 
varities  of  it  are  described  by  dermatologists,  according  to  the 
cause,  appearance,  and  duration. 

Causes. — These  are  external  and  internal.  Various  irritants 
apart  from  the  nettle  applied  to  the  surface  produce  the  wheals,  as 
the  bites  of  certain  insects  and  sometimes  turpentine.  The 
following  are  the  principal  internal  causes,  as  summarized  by 
Hillier:  1st,  profound  and  sudden  mental  emotion;  2d,  certain 
articles  of  diet,  as  shell-fish,  pork,  sausage,  cheese,  etc. ;  3d,  certain 
medicinal  substances,  as  copaiba,  valerian,  and  turpentine ;  4th, 
intestinal  worms,  though  it  is  probable  that  these  seldom  operate 
as  a  cause;  5th,  uterine  ailments,  as  hysteria. 

Prognosis,  Diagnosis. — The  prognosis  is  good,  though  the  chronic 
form  is  sometimes  tedious  and  troublesome.  The  occurrence  of 
the  wheals  and  the  possibility  of  producing  them  by  friction  serve 
to  distinguish  this  disease  from  all  others. 


702  PAPULAR    DISEASES. 

Treatment. — In  urticaria  due  to  any  recent  ingesta  of  an  irri- 
tating or  indigestible  character,  an  emetic  of  ipecacuanha  is  useful, 
followed  by  a  saline,  and  better  also  alkaline  aperient,  as  Rochelle 
salts.  An  aperient  of  this  character  is  useful  ordinarily  in  acute 
cases,  attended  by  febrile  reaction.  The  diet  for  several  days 
should  be  simple,  and  such  as  is  readily  digested,  as  fresh  beef, 
bread,  or  other  farinaceous  food,  and  milk.  Occasionally  the 
wheals  appear  periodically,  when  a  few  doses  of  quinine  effect  a 
promj^t  cure.  After  the  above  measures  have  been  employed,  the 
subsequent  treatment,  whether  tonic  or  otherwise,  depends  on  the 
condition  of  the  patient.  Little  benefit  accrues  from  local  measures. 
Sponging  the  surface  with  cool  water  to  which  a  little  vinegar  is 
added  relieves,  in  a  measure,  the  heat  and  tingling  of  the  wheals. 


CHAPTER   II. 

PAPULAR  DISEASES. 

The  three  papulae,  namely,  lichen,  prurigo,  and  strophulus, 
which  are  characterized  by  small  and  firm  elevations  upon  the 
skin,  occur  in  children ;  but  the  two  former  are  not  common,  and, 
as  they  do  not  differ  in  any  essential  particular  from  the  same 
diseases  in  the  adult,  they  will  not  be  treated  of  in  this  connection. 
Strophulus,  on  the  other  hand,  is  a  disease  peculiar  to  children.  It 
is  known  as  the  red  gum  or  white  gum  according  to  its  appearance, 
and  also  as  the  tooth  rash.  This  eruption  appears  usually  on  parts 
which  are  exposed,  as  the  face,  neck,  and  extremities ;  the  papules 
being  in  some  patients  of  the  size,  or  even  smaller,  than  a  pin's  head, 
while  in  other  cases  they  are  as  large  as  a  millet-seed. 

The  varieties  of  strophulus  described  by  dermatologists  are: — 

S.  intertinctus.  S.  candidus. 

"   confertus.  "  volaticus. 

"   albidus.  "  pruriginosus. 

The  following  are  the  characters  of  these  varieties :  S.  intertinctus, 
papules  a  bright  red,  and  occurring  chiefly  upon  the  cheeks, 
forearm,  and  back  of  hand;  often  intertindured  with  blushes  of 
erythema ;  it  lasts  from  two  to  four  weeks,  and  is  most  common  in 
young  infants.     S.  confertus,  papules  numerous,  and  closely  aggre- 


TREATMENT.  703 

gated,  paler,  continuing  longer  than  in  strophulus  intertinctus,  and 
likely  to  recur,  appearing  about  the  time  of  dentition,  and  most 
frequently  upon  the  arm.  Sometimes  certain  of  the  patches 
become  chronic,  slowly  disappearing,  and  leaving  the  skin  rough 
and  dry.  S.  volaticus  appears  usually  upon  the  arms  and  cheeks 
in  patches  of  about  a  dozen,  fewer  or  more,  papules,  which  soon 
disappear.  These  patches  reappear  at  intervals  for  two  or  three 
weeks,  and  are  attended  by  heat  and  itching,  though  not  intense. 
S.  albidus,  so  called,  should  really  be  placed  among  the  diseases  of 
the  sebaceous  glands,  and  described  under  another  name.  It 
appears  in  the  form  of  small  white  elevations  as  large  as  a  pin's 
head,  commonly  upon  the  face  and  neck,  and  produced  by  disten- 
sion of  the  sebaceous  glands  with  the  secreted  product.  The  term 
strophulus  candidus  is  applied  to  large  whitish  papules,  which 
appear  upon  the  sides  of  the  trunk,  shoulders,  and  arms  of  infants 
of  one  year  or  thereabouts,  and  disappear  in  about  one  week. 
They  are  apt  to  be  associated  with  the  papules  of  strophulus  con- 
fertus.  S.  pruriginosus  is  really  a  form  of  lichen,  occurring  chiefly 
over  the  age  of  one,  and  under  that  of  eight  or  nine  years.  The 
papules,  which  are  small  and  discrete,  usually  appear  over  a  large 
extent  of  surface,  ordinarily  upon  the  back,  front  of  the  chest,  the 
face  and  arms,  and,  as  they  are  scratched  from  the  itching,  minute 
dark  points  of  blood  collect  and  dry  upon  their  apices.  This  form 
of  strophulus  is  more  protracted  than  the  others,  and,  in  consequence 
of  the  irritation  produced  by  the  scratching,  pustules  of  ecthyma 
often  occur  among  the  papules.  The  apparent  cause  of  strophulus 
pruriginosus  is  a  mode  of  life  which  impoverishes  and  vitiates  the 
blood,  such  as  uncleanliness,  residence  in  damp,  dark,  overheated, 
and  overcrowded  apartments.  Atmospheric  heat  also  operates  as 
a  cause,  and  it  is  a  not  infrequent  disease  in  the  cities  during  the 
summer  months. 

The  various  eruptions  included  under  the  term  strophulus  have 
such  different  anatomical  characters,  that  a  proper  classification 
would  locate  some  of  them  in  other  groups  of  skin  diseases.  One 
form  of  it,  as  we  have  seen,  is  produced  by  distension  of  the  seba- 
ceous glands ;  in  other  and  the  majority  of  cases,  as  aj)pears  from 
the  recent  observations  of  Mr.  Fox,  its  seat  is  the  sweat  g-lands, 
and  in  others  still  the  papillary  layer  of  the  skin  as  in  lichen,  the 
papules  being  produced  by  an  exudation. 

Treatment. — Personal  cleanliness,  with  frequent  change  of  linen, 
and  daily  ablution  without  the  use  of  soap,  should  be  enjoined. 
Local  irritants,  which  might  aggravate  or  cause  the  disease,  should, 


704:  ECZEMA. 

SO  far  as  practicable,  be  removed.  Alkalies  in  cases  of  acidity  of 
the  prirnce  vice,  and  occasionally  mild  aperients,  are  required;  the 
food  should  be  bland,  but  nutritious,  and  if  the  child  is  nursing,  it 
may  be  necessary  to  attend  to  the  health  of  the  wet-nurse.  Favor- 
able hygienic  conditions  important  for  the  successful  treatment  of 
all  forms  of  strophulus  are  especially  required  in  strophulus  pruri- 
ginosus.  Nutritious  diet,  fresh  air,  quinine,  iron,  cod-liver  oil,  etc., 
should  be  prescribed  for  those  aft'ected  by  it.  The  following 
formula  is  recommended  for  sponging  the  surface  in  cases  of 
strophulus: — 

R.  Sodre  carbonat.  9j  ; 
Glycerinte  5ij ; 
Aq.  rosse  3TJ.     Misce. 


CHAPTER   III. 

ECZEMA  AND  SCABIES. 

Two  other  forms  of  cutaneous  eruption  should  be  treated  of 
among  the  diseases  of  children,  since  they  are  much  more  frequent 
in  them  than  in  adults,  although  they  occur  at  any  age.  The 
diseases  alluded  to  are  eczema  and  scabies,  both  placed  by  derma- 
tologists in  the  group  of  vesiculse. 

Eczema. 

This  is  one  of  the  most  common  inflammatory  afifections  of  the 
skin.  It  constituted  one-third  of  Devergie's  cases  and  one-sixth 
of  Hillier's.  It  is,  as  remarked  by  Niemeyer,  the  analogue  of 
catarrh  of  mucous  surfaces.  It  is  accompanied  by  a  discharge  of 
a  serous  appearance,  which,  confined  at  first  by  the  epidermis, 
usually  lifts  it  at  numerous  points,  forming  small  vesicles.  The 
vesicles  are  fragile,  soon  rupturing,  and  as  they  disappear  the 
surface  underneath  is  seen  to  be  red  and  abraded.  The  fluid  has 
the  property  of  stiffening  linen,  and  as  it  dries  it  is  succeeded  by 
a  crust  of  moderate  thickness  and  a  light-yellow  color.  The 
crusts  are  composed  mainly  of  inspissated  pus  and  epithelial  cells 
intermixed  with  granular  matter. 

Eczema  is  attended  by  a  sensation  of  heat  and  itching.  The 
vesicles  may  appear  only  at  the  commencement,  or  if  the  epidermis 
is  not  entirely  destroyed  there  may  be  successive  crops  of  them.  If 
the  epidermis  is  destroyed,  or  does  not  furnish  sufficient  resisting 


ECZEMA.  705 

power,  the  liquid  escapes  immediately  on  the  free  surface,  and 
vesicles  are  not  produced.  The  discharge  is  irritating,  and  tlie 
contiguous  surface  with  which  it  happens  to  come  in  contact  is 
usually  irritated  and  reddened  hy  it.  "While  these  superficial 
changes  occur,  the  deeper  portions  of  the  integument  become 
thickened  and  infiltrated. 

Eczema  occurs  in  various  parts  of  the  body,  and  it  is  sometimes 
designated,  according  to  its  locality,  as  faciei^  ccqntis,  etc.  In  its 
acute  stage  it  is  usually  attended,  especiallj^  if  the  patches  are  of 
large  size,  with  febrile  movement.  The  patient  ordinarily  presents 
a  pallid,  cachectic,  or  strumous  aspect,  has  a  poor  or  capricious 
appetite,  slightly  furred  tongue,  and  disordered,  usually  constipated 
bowels ;  but  the  general  condition  and  the  symptoms  vary  con- 
siderably in  different  cases. 

There  are  three  varieties  of  eczema,  namely,  simplex,  rubrum, 
and  impetiginodes.  Eczema  simplex  is  most  common  in  the 
summer  months,  being  produced  by  the  heat  of  the  atmosphere. 
External  irritants,  applied  to  the  skin,  as  strong  soap,  sometimes 
cause  it.  The  patient  complains,  perhaps,  of  febrile  symptoms,  and 
soon  an  erythematous  patch  of  greater  or  less  extent  appears,  upon 
which  a  cluster  of  the  vesicles  of  eczema  arise.  These  break, 
forming  slight  crusts,  which  are  soon  detached,  and  the  disease 
declines,  or  it  may  continue  longer,  with  a  successive  eruption  of 
vesicles. 

Eczema  rubrum  is  a  more  severe  form  of  the  disease.  The  fever 
and  the  local  symptoms  are  greater  than  in  the  preceding  variety, 
and  the  eczematous  patch  presents  the  appearance  of  a  more 
intense  inflammation.  The  vesicles,  which  are  often  so  minute  as 
to  be  with  difficulty  recognized,  and  so  numerous  as  to  become 
confluent,  are  soon  ruptured,  and  their  contents,  with  the  secretion 
and  exudation  from  the  surface,  dry  into  yellowish  or  brownish- 
yellow  scabs.  The  discharge  is  more  irritating,  as  it  is  more 
abunda,nt,  than  in  eczema  simplex,  and  the  adjacent  skin  usually 
is  inflamed  from  its  contact.  Its  most  common  seat  is  about  the 
flexures  of  the  body,  but  it  not  infrequently  extends  to  a  greater 
or  less  extent  along  the  surface. 

Eczema  impetiginodes  is  common  in  young,  debilitated  children, 
in  whom,  in  consequence  of  the  cachexia,  inflammations,  of  what- 
ever character,  are  apt  to  be  suppurative.  This  form  of  eczema 
presents  at  first  the  symptoms  and  features  of  eczema  rubrum,  but 
the  transparent  liquid  of  the  vesicles  soon  becomes  opaque,  from  the 
generation  and  admixture  of  pus  corpuscles.  The  crusts,  which 
45 


706  ECZEMA. 

form  from  the  rupture  and  desiccation  of  the  vesiculo-pustular 
eruption,  are  thick  and  greenish-jellow,  and  in  infants  the 
sebaceous  glands,  which  are  involved  in  the  inflammation,  pour 
out  an  abundant  secretion,  increasing  the  thickness  of  the  crusts. 
This  form  of  eczema  is  most  common  in  infancy,  and  its  usual  seat 
is  upon  the  scalp. 

Other  varieties  of  eczema  are  described  by  writers.  When  the 
inflammation  does  not  entirely  abate,  but  sufiicient  of  it  remains 
to  cause  scaliness,  it  is  designated  squamosum.  This  form  may 
continue  many  months.  Eczema  may  also  become  chronic,  with  a 
free  and  irritating  discharge,  the  eczema  ichorosum  of  authors. 
When  eczema  is  severe,  or  protracted,  various  structural  changes 
occur  in  the  inflamed  integument,  as  fissures,  oedema,  papillary  or 
warty  out-growths,  hyperplasia  of  the  connective  tissue,  and  sub- 
varieties  of  the  disease  are  described  by  writers,  according  to  these 
characters.  It  is  seen,  therefore,  that  there  is  considerable  varia- 
tion in  the  appearance  of  an  eczematous  eruption,  but  its  distinc- 
tive feature  is  the  occurrence  of  a  discharge  of  a  serous  appearance 
from  the  inflamed  surface,  which  lifts  the  cuticle,  and  appears  to 
the  eve  in  the  form  of  minute  vesicles.  This  discharo-e  is  some- 
times  insignificant,  almost  absent,  but  the  form  of  the  vesicles, 
although  they  may  abort,  can  be  made  out  in  the  commencement 
of  nearly  all  cases. 

The  eczema  of  infants  is  of  most  interest  to  us,  as  it  is  not  only 
so  common,  but  is  one  of  the  most  troublesome  of  the  cutaneous 
aflfections.  It  is  really  in  its  commencement  in  most  cases  an 
eczema  simplex,  or  rubrum,  or  a  combination  of  the  two.  Its 
seat  is  upon  the  scalp,  behind  the  ears,  upon  the  face,  and  in  the 
flexures  of  the  joints.  Unless  proj^erly  treated,  it  frequently 
becomes  chronic,  lasting  several  months,  being  usually,  when  pro- 
tracted, an  eczema  impetiginodes.  The  health  of  the  child  after  a 
time  suffers.  It  becomes  more  pallid,  its  flesh  more  soft  and  flabby, 
and  the  appetite  impaired.  The  heat,  itching,  and  pain  increase 
the  discomfort. 

Diagnosis. — Eczema  presents  in  different  instances  so  different 
an  appearance  that  it  is  not  always  readily  diagnosticated.  It  will 
aid  in  its  dia2;nosis  to  recollect  that  it  is  in  its  nature  a  moist 
disease,  affecting  primarily  and  chiefly  the  upper  portion  of  the 
derma  and  the  malpighian  layer,  and  although  it  may,  at  present, 
present  a  dry  or  scaly  appearance  (E.  squamosum)  yet  its  history 
will  show  that  there  has  been  a  discharge  or  moisture.  In  a  large 
proportion  of  cases,  the  physician  is  not  able  to  detect  vesicles, 


TREATMENT.  707 

since  they  are  fragile  and  transient,  breaking  in  the  first  thirty- 
six  hours,  and  not  reappearing.  Still,  when  vesicles  are  absent, 
we  sometimes  observe  around  the  margin  of  the,  patch  an  appear- 
ance which  indicates  that  they  have  been  there.  Their  minuteness 
is  occasionally  such  that  they  may  escape  notice,  on  a  cursory 
inspection,  when  they  are  present  and  well  defined.  Acute  ec- 
zema, aftecting  a  considerable  extent  of  surface,  is  attended  by 
decided  febrile  movement,  and  might  be  mistaken  for  one  of  the 
eruptive  fevers,  but  the  absence  of  certain  distinctive  appearances, 
which  characterize  these  fevers,  and  the  speedy  appearance  of 
vesicles  and  moisture,  establish  the  diagnosis.  Eczema  can  be 
readily  diagnosticated  from  ordinary  erythema,  which  is  a  super- 
ficial inflammation  without  moisture.  The  location  of  erythema 
intertrigo  serves  for  its  diagnosis,  as  it  is  evidently  produced  by 
the  attrition  of  opposite  surfaces  of  the  skin.  Moreover  it  lacks 
the  vesicular  eruption,  and  the  discharge  does  not  stiiFen  linen  like 
that  of  eczema.  Lichen,  when  acute,  presents  some  resemblance 
to  eczema,  but  it  is  dry  and  papular,  the  papules  though  small 
being  detected  by  the  finger  as  well  as  sight.  The  large  and 
irregular  phl^a^teena,  intense  inflammation,  and  cedema,  and  mode 
of  extension  of  erysipelas,  large,  scattered,  and  non-inflammatory 
vesicles  of  sudamina,  scattered  and  accuminate  vesicles,  without 
surrounding  inflammation  of  scabies,  are  so  different  from  the 
eczematous  eruption  that  the  differential  diagnosis  is  readily 
made.  Herpes  circinatus  can  be  distinguished  from  eczema  by  its 
circular  shape,  larger  size,  and  greater  permanence  of  the  vesicles, 
and  the  delicate,  branny  scales,  which  consist  rather  of  epithelial 
cells  than  the  product  of  exudation  as  in  eczema. 

Treatment. — Hardy  believes  that  there  is  a  diathesis  which 
manifests  itself  in  certain  cutaneous  eruptions,  especially  eczema, 
pityriasis,  psoriasis,  and  lichen.  This  diathesis  he  designated 
dartrous,  and  those  who  have  it  may  seem  to  have  good  general 
health,  but  not  in  reality.  Their  skin  is  readily  affected  by 
irritants ;  it  is  dry,  the  perspiration  being  deficient,  and  it  is  liable 
to  pruritus.  The  dartrous  diseases  of  the  skin  are  non-contagious, 
often  hereditary,  prone  to  reappear  and  invade  new  portions  of 
the  surface,  protracted  in  their  nature,  accompanied  by  itching, 
and  healing  without  cicatrization.  According  to  this  theory,  there- 
fore, the  predisposing  cause  of  these  diseases  is  to  be  found  in  the 
diathesis,  or  the  state  of  the  blood,  but  in  ordinary  cases  there  are 
certain  exciting  causes,  which  may  be  found  in  the  occupation, 
mode  of  life,  or  hygienic  conditions.     The  mucous  surfaces  are 


708  ECZEMA, 

often  also  affected,  a  dartroiis  bronchitis,  leueorrhoea,  etc.,  occurring. 
Such  is  the  theory  of  Hardy  and  the  French  school. 

That  there  is  in  a  large  proportion  of  cases  of  eczema,  and  of 
the  other  diseases  alluded  to  above,  a  diethetic  state  by  whatever 
name  known,  underlying  and  causing  the  eruption,  is  not,  however, 
a  new  belief;  and  hence  the  term  herpetic  diathesis,  or  dyscrasia, 
by  which  this  state  has  long  been  designated.  Not  infrequently, 
especially  among  the  city  poor,  eczema  is  obviously  one  of  the 
protean  manifestations  of  the  scrofulous  diathesis,  the  eruption 
disappearing  under  anti-strumous  remedies.  It  is  a  matter  of 
importance  as  regards  the  therapeutics  to  recognize  a  constitutional 
cause  in  eczema,  whether  it  be  a  diathesis,  or,  as  is  not  infrequently 
the  case,  is  of  a  more  transient  nature,  the  result  of  some  influence, 
which  temporarily  impairs  the  health.  But  while  it  is,  therefore, 
apparent  that  internal  treatment  is  ordinarily  required  for  the 
successful  treatment  of  eczema,  there  are  certain  cases  in  which 
the  system  is  not  in  fault,  and  local  measures  alone  are  required, 
as  when  the  eruption  is  due  to  the  direct  effect  of  the  sun's  rays, 
or  friction. 

General  Treatment. — In  most  recent  cases  of  eczema,  great 
benefit  results  from  an  occasional  purgative  dose.  This  is  most 
useful  in  the  sthenic  cases,  when  accompanied  by  considerable 
pyrexia,  a  full  pulse  and  troublesome  pruritus.  An  occasional 
dose  of  calomel,  or  a  saline  purgative,  should  be  given.  By  its 
derivative  effect  it  diminishes  the  intensity  of  the  cutaneous 
inflammation,  and  the  patient  experiences  a  degree  of  relief  from 
the  itching.  In  feeble  infants  the  hydrarg.  com.  cretee,  followed 
by  syrup  of  rhubarb,  is  sometimes  preferable.  The  purgative 
often  requires  to  be  repeated  once  or  twice  weekly. 

If  the  child  is  scrofulous,  the  proper  internal  remedies  for  daily 
use  are  cod-liver  oil,  and  the  syrup  of  the  iodide  of  iron.  The 
constitutional  state,  whatever  its  exact  character  or  cause,  is  most 
frequently  one  of  debility,  and  therefore  tonics,  vegetable  and 
ferruginous,  are  useful.  We  have  in  addition  one  internal  remedy, 
the  value  of  which  is  acknowledged  by  all  dermatologists,  namely 
arsenic.  Wilson  regards  it  a  specific  for  this  disease.  The  follow- 
ing is  the  formula  which  he  recommends,  and  which  will  be  found 
useful  for  ordinary  cases: — 

^.  Villi  ferri, 

Syrup  tolntani,  aa  |ss  ; 

Liq.  potas.  arsenit.  tn.  xxxij  ; 

Aquae  anethi  3J.     Misce. 


LOCAL    TIIEATMENT.  709 

Dose,  one  drachm,  with  or  after  the  meals,  three  times  daily. 
An  infant  from  six  to  twelve  months  old  can  take  from  one  to 
two  minims  of  Fowler's  solution.  Prominent  among  the  imme- 
diate and  preventible  causes  of  eczema  is  some  error  of  diet.  If 
the  patient  is  a  nursing  infant,  the  state  of  the  health  of  the  wet- 
nurse  should  be  attended  to,  and  if  it  is  in  fault,  she  should  be 
placed  upon  tonic  or  other  treatment.  "If,"  says  Mr.  Fox,  "the 
child  is  being  brought  up  by  hand,  corn  flour,  and  other  purely 
starchy  compounds,  I  think  should  be  avoided.  Fine  baked  flour, 
and  milk  wheat  phosphates,  is  perhaps  the  best  compound." 

Local  Treatment. — As  the  skin  in  eczema  is  in  an  inflamed 
and  sensitive  state,  and  easily  irritated,  soothing  local  treatment 
is  required  in  recent  or  acute  eczema.  In  the  commencement  of 
the  eruption,  one  of  the  following  formulae  will  be  found  useful: — 

I^.  Liq.  plumbi  subacetat., 
Villi  opii,  aa  gj  ; 
TJng.  sambuci  ,f  j. 

To  be  applied  frequently  over  the  eczematous  patch.  Simple 
cerate  may  be  used  in  place  of  the  orange  flower  ointment : — 

^..   Gum  camphor  ^ss; 

Alcohol  q.  s.     Misce. 
Adde 

Zinci  oxid., 

Pulv.  amyli,  aa  3iv. 

To  be  dusted  upon  the  surface.  This  powder  is  useful  both  in 
treating  the  eruption  and  for  the  burning  sensation.  A  simple 
water  dressing,  or  bathing  with  milk  and  water,  is  also  useful, 
when  the  inflammation  is  in  its  first  stages,  and  active,  and  the 
local  symptoms  are  severe.  The  following  prescrij^tion  employed 
by  Mr.  Fox  is  also  beneficial  in  such  cases: — 

R.  Sodre  borat.  ^ij  ; 
Zinci  oxid.  3J  ; 
Liq.  plumb,  subacetat.  ^ij ; 
Aq.  calcis  §vj  to  3viij.     Misce. 

When  the  eruption  has  continued  for  a  little  time,  and  the 
pyrexia  and  local  symptoms  are  somewhat  moderated,  the  pre- 
parations of  zinc  are  most  highly  esteemed  for  local  treatment 
both  in  this  country  and  in  Europe.  In  Germany,  on  the  other 
hand,  preference  is  given  to  the  milder  mercurial  ointments,  as  the 
white  precipitate,  considerably  diluted.  But  the  result  of  the 
zinc  treatment  is  ordinarily  satisfactory,  and  it  should  always  be 
employed,  when  the  eruption  involves  a  considerable  extent  of 


710  ECZEMA. 

surface.  After  the  crusts  have  been  softened  by  a  poultice  or 
glycerine,  and  to  a  considerable  extent  removed,  the  following 
ointment  should  be  thickly  applied  to  the  surface,  two  or  three 
times  daily.  JSTo  soap  or  other  irritant  should  be  employed  after 
the  treatment  has  been  commenced,  but  any  bathing  which  may 
be  required  should  be  by  simple  water,  milk  and  water,  mucilagi- 
nous water,  or  bran  water.  The  following  is  also  a  good  formula 
for  ordinary  cases  of  eczema : — 

R.  Ziuci  oxid.  5ij  ; 
Glycerinse  5j  ; 
Liq.  plumbi  subacetat.  5js9  ; 
Aquae  calcis  ^viij.     Misce. 

If  the  burning  and  itching  remain  a  troublesome  symptom, 
notwithstanding  this  treatment,  one  of  the  following  washes  may 
be  frequently  applied  in  addition : — 

B.  Potas.  cyanid.  gr.  xxiv ; 
Aquse  §viij.     Misce. 

^..  Sodse  borat.  3ij  ; 
Aq.  lauro-cerasi  gj  ; 
Aq.  sambuci  ,^jss.     Misce. 

;^.  Liq.  ammonipe  acetat,  1  part ; 
Aq.  camphonie,  2  parts.     Misce. 

If  the  above  treatment  fail  to  relieve  eczema,  or  if  the  improve- 
ment is  slow  and  unsatisfactory,  the  ointment  of  the  nitrate  of 
mercury,  or  of  ammoniated  mercury,  will  frequently  produce 
speedy  improvement  and  cure.  I  have  noticed  the  most  benefit 
from  it  in  chronic  cases,  in  which  the  amount  of  inflammation 
was  quite  moderate.  Niemeyer  says,  "The  topical  remedies, 
which  I  would  recommend  before  all  others,  are  the  white  pre- 
cipitate in  the  form  of  an  ointment  (hydrarg.  ammoniat,  3j  adipis 
sj)  and  corrosive  sublimate  in  weak  solution  (hydrarg.  bichlor.  gr. 
j-ij,  aquse  destillat.  3J),  .  .  .  since  in  the  great  majority  of  cases 
they  amply  suffice  to  effect  a  rapid  and  complete  cure,  even  of  the 
most  obstinate  forms  of  eczema."  The  preparations  of  lead  and 
zinc,  he  believes,  "  stand  next  in  virtue  to  the  white  precipitate 
salve,  and  the  solution  of  corrosive  sublimate,"  as  remedies  for 
eczema.  In  the  foregroino;  remarks  no  allusion  has  been  made  to 
those  cases  of  eczema  which  are  due  to  the  syphilitic  dyscrasia. 
Evidently  mercurials  are  essential  to  the  successful  treatment  of 
this  form  of  the  disease,  and  the  white  precipitate,  citrine,  or  simple 
mercurial  ointment,  properly  diluted,  should  always  be  prescribed 


SCABIES. 


711 


for  local  treatment  of  sucli  cases  instead  of  the  prej^arations  of 
zinc  or  lead  (Art.  Syphilis). 

Scabies. 

The  diseases  of  tlie  skin  previously  considered  are  non-conta- 
gious. Scabies,  on  the  other  hand,  is  one  of  the  most  contagious 
diseases  by  contact.  It  is  produced  by  an  animal  parasite,  known 
as  the  itch-mite,  or  acarus  scabiei.     The  inflammation  is  caused  by 


Fig.  1. 


Fig.  2. 


Fig.  3. 


Fig.  4. 

0 
0 

Fig.  1.  The  itch  animalcule,  acarus  scabiei,  viewed  upon  the  back,  showing  its  figure  and  the  ar- 
rangement of  its  spines  and  filaments.  The  female,  which  is  somewhat  larger  than  the  male,  has  a 
length  of  1-SOth  to  l-60th  of  an  inch. 

Fig.  2.  The  foot  and  la.st  joints  of  the  leg  of  the  itch  animalcule. 

Fig.  3.  The  male  itch  animalcule,  viewed  upon  the  under  surface,  showing  its  legs  and  lobulated  feet. 

Fig.  4.  Ova  of  the  itch  animalcule. 

the  female  only,  which  burrows,  making  for  itself  a  canal,  or 
cuniculus,  in  which  its  eggs  are  deposited.  The  male  does  not 
burrow,  but  conceals  itself  under  the  scales  or  crusts  which  result 
from  the  inflammation  produced  by  its  partner,  or  it  burrows  only 
sufficiently  to  produce  a  covering  and  shelter.  From  observations 
made  by  Eichstedt,  Gudden,  and  others,  the  female  has  been  found 
within  half  an  hour  after  being  placed  upon  the  skin  to  have  con- 
cealed herself  in  the  epidermis,  and  the  cuniculus  which  she  con- 
structs is  arched  and  tortuous,  and  four  or  five  lines  in  length, 
shorter  or  longer.  The  acarus  has  the  shape  of  a  tortoise.  It  can 
when  fully  grown  be  detected  by  the  eye  as  a  minute  whitish  point. 
The  young  acarus  has  six,  the  mature  eight,  articulated  legs,  with 
suckers  upon  the  two  anterior  pairs,  and  hairs  on  the  posterior. 
The  head,  which  can  be  elongated  or  retracted,  is  provided  with 
two  jaws.   The  upper  surface  is  covered  with  spines  directed  back- 


712  SCABIES. 

wards  so  fis  to  prevent  retrogression  in  the  burrow.  Slie  leaves 
behind  her  in  tlie  cuniculus,  as  she  advances,  her  moulted  skin, 
excreta,  and  eggs,  which  hatch  on  the  eleventh  day.  The  mother 
acarus  is  alwaj^s  found  at  the  remote  end  of  the  burrow,  where  it 
can  be  seen  by  the  unassisted  eye  as  a  minute  whitish  or  sometimes* 
brownish  speck,  and  from  which  it  can  be  lifted  by  the  point  of  a 
needle  to  which  it  clings.  The  cuniculi  can  also  be  seen  by  the 
naked  eye,  looking,  says  ISTiemeyer,  like  the  "  scars  of  needle 
scratches,"  and  containing  the  young  acari  in  various  stages  of 
growth. 

The  acarus  by  its  burrowing  produces  an  irritation,  and  trouble- 
some itching,  which  is  the  chief  cause  of  the  suflering  of  the  patient. 
At  the  point  where  the  acarus  penetrates  the  cuticle  the  inflam- 
mation gives  rise  to  a  single,  small,  and  accuminate  vesicular  or 
papular  eruption,  the  cuniculus  extending  away  from  it.  "We 
often  find  ecthymatous  pustules  and  abrasions  intermingled  with 
the  vesicles,  the  result  of  the  frequent  scratching.  The  itching  is 
most  intense,  and  the  acarus  most  active,  at  night,  when  the  patient 
is  warm  in  bed.  Scabies  most  frequently  appears,  especially  in 
adults,  first  upon  the  hands,  between  the  fingers,  where  the  skin  is 
thin,  and  it  extends  thence  along  the  forearm,  and  over  the  thighs 
and  abdomen.  In  children  it  not  infrequently  occurs  upon  the 
buttocks,  thighs,  feet,  etc.,  while  the  hands  and  forearm  escape. 

Diagnosis. — Correct  diagnosis  is  important,  because  the  treat- 
ment required  is  different  from  that  in  any  other  exanthem,  and 
because  the  suspicion  of  having  this  disease  always  renders  one 
solicitous  to  know  the  exact  nature  of  the  eruption.  Scabies  can 
be  diao-nosticated  from  those  diseases  for  which  it  might  be 
mistaken  by  the  following  characters:  its  occurrence  where  the 
cuticle  is  thin  and  delicate,  as  between  the  fingers,  along  the  ante- 
rior aspect  of  the  forearm,  upon  the  abdomen,  thighs,  and  inside 
of  the  feet ;  small  size,  accuminate  shape,  and  isolated  position 
of  vesicles ;  the  intermingling  with  the  vesicles  of  other  forms  of 
eruption,  as  papules  and  pustules,  and  the  presence  of  linear  scars 
and  abrasions  produced  by  the  scratching ;  itching  most  intense 
at  night;  absence  of  fever;  absence  of  the  .disease  from  posterior 
aspect  of  body  and  arms,  and  from  head  and  face.  Scabies  may 
be  distinguished  by  the  vesicular  character  of  the  eruption  from 
all  other  exanthematic  affections  except  eczema,  sudamina,  and 
herpes.  Eczema  is  most  common  on  the  scalp  and  face,  where 
scabies  does  not  occur,  and  unlike  scabies  its  vesicles  are  round 
and  thickly  aggregated  in  clusters;  in  eczema  there  is  a  smarting 


TREATMENT.  713 

or  prickling  sensation  very  different  from  the  intense  itching  of 
scabies.  In  herpes  the  vesicles  are  large,  rounded,  and  in  clusters, 
and  attended  by  a  burning  or  pricking  sensation,  with  but  little 
itching.  The  eruption  in  sudamina  is  vesicular  and  discrete,  as 
in  scabies,  but  it  is  globular,  and  accompanied  by  no  itching  or 
other  local  symptoms. 

Treatment. — As  scabies  is  due  to  a  species  of  acarus  which 
burrows  in  the  epidermis,  it  can  only  be  treated  successfully  by 
measures  which  destroy  this  animalcule.  If  it  is  destroyed,  the 
disease  gets  well  of  itself.  Sulphur  has  been  employed  for  a  long 
period  for  this  jDurpose,  since  sulphurous  acid,  which  is  evolved 
from  the  sulphur,  is  destructive  to  the  animalcule.  The  unguen- 
tum  sulphuris,  if  thoroughly  applied,  will  rarely  fail  to  eradicate 
the  disease.  The  internal  use  of  sulphur  aids  the  external  treat- 
ment, since  a  portion  of  the  gas  which  is  generated  escapes  through 
the  pores  of  the  skin.  The  chief  objection  to  the  employment  of 
sulphur  is  its  exceedingly  unpleasant  odor,  which  is  noticeable, 
however  disguised  by  perfume.  Sulphur  or  any  other  substance 
employed  externally  has  more  effect  if  it  is  preceded  by  a  bath, 
which  softens  the  epidermis,  and  therefore  favors  the  entrance  of 
the  remedy  into  the  pores  of  the  skin  and  the  cuniculi. 

Helmerich's  ointment  is  very  efiectual  in  the  treatment  of 
scabies.  It  consists  of  two  parts  of  sulphur,  one  of  carbonate  of 
potash,  and  eight  of  lard.  "M.  Hardy  afterwards  perfected  the 
method,  so  as  radically  to  cure  the  disease  in  two  hours.  He 
proceeds  in  the  following  manner:  The  patient  first  undergoes  a 
friction  of  his  whole  body  for  half  an  hour  with  soft  soap,  in  order 
to  cleanse  the  skin  and  break  up  the  burrows ;  a  warm  bath  of  an 
hour's  duration  follows,  during  which  the  skin  is  thoroughly 
rubbed,  in  order  to  complete  the  destruction  of  the  burrows ;  after 
which  frictions  for  half  an  hour  and  upon  the  whole  surface  are 
practised  with  Helmerich's  ointment.  This  completes  the  cure. 
Out  of  four  hundred  patients  subjected  to  this  treatment,  only 
four  returned  to  the  hospital."  (Stille's  Thercq^eutics,  etc.,  vol.  ii. 
page  516.) 

M.  Albin  Gras  experimented  with  different  substances,  in  order 
to  ascertain  their  relative  destructiveness  to  the  acarus.  The  fol- 
lowing table  gives  some  of  the  results  of  his  experiments: — 

Immersed  in  pure  water  the  acarus  was  alive  after  three  hours. 

"  saline         "  "       moved  freely  after  three  hours. 

"  Goulard's  solution  the  acarus  lived  after  one  hour. 

"         olive,  almond,  or  castor  oil  the  acarus  lived  more  than  two  hours. 


71i  SCABIES, 

Immersed  in  lime--water  the  acarus  died  in  tliree-fourths  of  an  hour. 
"  vinegar  "  "        twenty-  minutes. 

alcohol  "  "  "  ** 

"  turpentine  "  "        nine  " 

"         iodide  of  potassium  the  acarus  died  in  four  to  six  minutes. 

It  is  seen  that  vinegar,  lime-water,  alcoliol,  turpentine,  and 
iodide  of  potassium  destroy  the  acarus  in  a  short  time.  They 
may  be  employed  in  the  same  manner  as  the  sulphur  ointment. 
Camphor  is  also  destructive  to  this  animalcule,  and  the  linimentum 
camphora?,  thoroughly  applied,  is  a  good  remedy  for  uncomplicated 
scabies. 

In  order  to  avoid  the  odor  of  sulphur  which  is  so  offensive,  one 
of  the  following  ointments  may  be  employed,  if  the  patient  is 
fastidious. 

R.  Unguent,  hydrarg.  ammoniat.  3J ; 
Moschi  gr.  ij  ; 
01.  lavendul.  gtt.  ij  ; 
01.  amygdal.  sj.     Misce.  (From  Wilson.) 

This  should  not  be  used  if  the  scabies  is  extensive,  but  the  fol- 
lowing, which  is  recommended  by  Bazin,  and  is  said  to  cure  the 
disease  with  three  applications: — 

R.  Anthemis  pulv., 
Adipis, 
01.  olivfe,  aa  §j.     Misce. 

In  cases  which  have  been  protracted,  and  in  which  ecthymatous 
and  other  secondary  eruptions  have  occurred,  the  scabies  can 
ordinarily  be  readily  cured,  while  the  other  eruptions  remain  and 
disappear  more  slowly.  A  knowledge  of  this  is  important,  since 
the  sulphur,  or  other  ointment  employed  lor  the  cure  of  scabies, 
should  be  discontinued  when  the  itching  ceases,  and  vesicles  no 
longer  appear,  and  tonic,  or  other  treatment  appropriate  to  cure 
these  secondary  eruptions,  should  be  employed  instead.  The 
sulphur  ointment  continued,  after  the  scabies  is  cured,  does  harm, 
as  it  irritates  the  cuticle. 


APPENDIX. 


The  modes  of  preparing  milk  for  infants,  which  are  described  in  the 
chapters  relating  to  feeding,  are  simple,  and  are  therefore  preferable  to 
more  difficult  processes.  If  the  milk  thus  prepared  disagree,  other 
formulae  may  be  employed  which  furnish  a  product  more  closely  re- 
sembling human  milk.  The  two  following,  which  are  extracted  from 
Routh's  Treatise  on  Infant  Feeding,  are  among  the  best.  In  both  the 
amount  of  casein  is  diminished  and  of  sugar  increased.  First,  Prof. 
Falkland's  method : — 

"One-third  of  a  pint  of  pure  milk  is  allowed  to  stand  until  the  cream 
has  risen.  The  latter  is  removed,  and  to  the  blue  milk  thus  obtained, 
about  a  square  inch  of  rennet  is  to  be  added,  and  the  milk  vessel  placed 
in  warm  water.  In  about  five  minutes  the  curd  will  have  separated, 
and  the  rennet,  which  may  again  be  repeatedly  used,  being  removed, 
the  whey  is  carefully  poured  off,  and  immediately  heated  to  boiling,  to 
prevent  its  becoming  sour.  A  further  quantit}'  of  curd  separates,  and 
must  be  removed  by  straining  through  calico.  In  one-quarter  of  a  pint 
of  this  hot  whey  is  to  be  dissolved  three-eighths  of  an  ounce  of  milk 
sugar ;  and  this  solution,  along  with  the  <;ream  removed  from  the  one- 
third  of  a  pint  of  milk,  must  be  added  to  half  a  pint  of  new  milk.  This 
will  constitute  the  food  for  an  infant  of  from  five  to  eight  months  old 
for  twelve  hours;  or,  more  correctly  speaking,  it  will  be  one-half  of  the 
quantity  required  for  twenty-four  hours.  It  is  absolutely  necessary 
that  a  fresh  quantity  should  be  prepared  every  twelve  hours  ;  and  it  is 
scarcely  necessary  to  add  that  the  strictest  cleanliness  in  all  the  vessels 
used  is  indispensable." 

The  second  method  is  that  by  Mr.  Lobb: — 

"Haifa  pint  of  new  milk  is  set  aside  for  the  cream  to  separate,  which 
latter  is  removed;  and  to  the  blue  milk  half  a  teaspoonful  of  prepared 
rennet  is  added ;  this  is  placed  over  the  fire  and  heated  until  the  curd 
has  separated,  when  it  is  broken  up  with  a  spoon,  and  the  whe}^  poured 
off.  In  winter,  three  drachms  of  powdered  sugar  of  milk  are  added  to 
this  warm  whej^;  and  the  whole  is  mixed  with  half  a  pint  of  new  milk. 
In  summer,  three  drachms  and  a  half  of  sugar  of  milk  are  added,  and 
with  the  new  milk  are  all  boiled  together." 


716  APPENDIX. 

I  have  had  no  experience  in  the  use  of  milk  pi*epared  b}'  either  of 
these  two  methods.  An  objection  to  the  latter  process  is  the  boiling, 
which  is  believed  to  impair  the  qualit^^  of  milk. 

The  above  formuljB  are  designed  especiall}'  for  infants  who  have  not 
reached  the  age  at  which  it  is  proper  to  give  farinaceous  food.  They 
maj'  also  be  employed  for  older  infants  who  are  in  a  state  of  feebleness, 
and  whose  digestive  organs  are  capable  of  assimilating  only  the  blandest 
preparations  of  food. 

Meigs,  in  his  treatise  on  diseases  of  children  (page  267),  recommends 
an  article  of  diet  which  he  states  agrees  better  with  the  digestive  s}' stem 
of  the  infant  than  any  other  kind  of  food  which  he  has  emplo3'ed.  The 
mode  of  preparation  and  the  proportions  are  as  follows :  "  A  scruple  of 
gelatine  (or  a  piece  two  inches  square  of  the  flat  cake  in  which  it  is  sold) 
is  soaked  for  a  £,hort  time  in  cold  water,  and  then  boiled  in  a  half  a  pint 
of  water,  until  it  dissolves,  about  ten  or  fifteen  minutes.  To  this  is 
added,  with  constant  stirring,  and  just  at  the  termination  of  the  boiling, 
the  milk  and  arrowroot,  the  latter  being  previously  mixed  into  a  paste 
with  a  little  cold  water.  After  the  addition  of  the  milk  and  arrowroot, 
and  just  before  the  removal  from  the  fire,  the  cream  is  poured  in,  and  a 
moderate  quantity  of  loaf  sugar  added.  The  proportions  of  milk, 
cream,  and  arrowroot  must  depend  on  the  age  and  digestive  powers  of 
the  child.  For  a  healthy  infant,  within  the  month,  I  usually  direct  from 
three  to  four  ounces  of  milk,  half  an  ounce  to  an  ounce  of  cream  and  a 
teaspoonful  of  arrowroot,  to  half  a  pint  of  water.  For  older  children 
the  quantity  of  milk  and  cream  should  be  gradually  increased  to  a  half 
or  two-thirds  milk,  and  from  one  to  two  ounces  of  cream.  I  seldom 
increase  the  quantity  of  gelatine  or  arrowroot." 

Baron  Liebig  has  also  recommended  a  soup  for  infants  which  he 
believes  to  be  the  best  substitute  for  human  milk.  By  the  mode  of 
preparation  starch  is  transformed  into  sugar  and  dextrin,  a  change 
which,  when  farinaceous  substances  are  used  in  the  usual  way,  is  effected 
in  the  stomach,  and  thus  this  organ  is  relieved  from  a  part  of  the  burden 
of  di2:estion. 

"  The  following  is  the  best  way  of  preparing  this  food:  Half  an  ounce 
of  wheaten  flour,  and  an  equal  quantity  of  malt  flour,  seven  grains  and 
a  quarter  of  bicarbonate  of  potash,  and  one  ounce  of  water  are  to  be 
well  mixed;  five  ounces  of  cow's  milk  are  then  to  be  added,  and  the 
whole  put  on  a  gentle  fire.  When  the  mixture  begins  to  thicken,  it  is 
removed  from  the  fire;  stirred  during  five  minutes ;  heated  and  stirred 
again,  till  it  becomes  quite  fluid,  and  finally'  made  to  boil.  After  tlie 
separation  of  the  bran  b}^  a  sieve,  it  is  ready  for  use.  By  boiling  it  for 
a  few  minutes,  it  loses  all  taste  of  the  flour." — {Lancet^  Januar}^  Ith, 
1865;  Braithwaite^s  i2(^<7'os.,  July,  1865.) 

Liebig  has  succeeded  in  preparing  an  article  the  ingredients  of  which, 


APPENDIX.  717 

and  their  relative  proportion,  are  very  similar  to  those  of  hnman  milk. 
It  has,  however,  twice  tlic  consistence  of  milk,  or,  as  Liebig  expresses 
it,  is  "tlie  double  concentration"  of  that  secretion. 

Dr.  Ilassell,  in  a  conimunicntion  in  reference  to  this  food  to  the 
London  Lancet  for  July  2yth,  18G5,  says:  "It  appears  to  me  that  the 
great  merit  of  Liebig's  preparation  consists  in  the  use  of  malt  flour  as  a 
constituent  of  the  food;  this,  from  the  diastase  contained  in  it,  exercises, 
when  the  fluid  food  or  soup  is  properly  prepared,  a  most  remarkable 
influence  upon  the  starch,  quickly  transforming  it  into  dextrin  and 
sugar,  so  that  in  the  course  of  a  few  minutes  the  food,  from  being  thick 
and  sugarless,  becomes  comparatively  thin  and  sweet." 

"  Correct  and  ingenious  as  are  the 

principles  upon  which  this  food  has  been  designed,  yet  the  directions 
given  for  its  preparation  are  certainly  open  to  considerable  improve- 
ment. Thus,  Liebig  directs  that  the  malt  should  be  ground  in  a 
common  coffee  mill,  and  the  coarse  powder  passed  through  a  sieve. 
This  necessitates  the  subsequent  straining  of  the  food,  a  tedious  opera- 
tion, in  order  to  remove  the  bran  and  remaining  particles  of  husk. 
And  further,  that  the  food  should  be  put  upon  a  gentle  fire  previous 
to  its  being  finally  boiled.  Now,  a  gentle  heat  may  mean  almost  any 
temperature  nearly  up  to  the  boiling  point;  and  since  the  action  of  the 
diastase  is  destroyed  at  about  150°  F.,  the  temperature  should  never  be 
allowed  to  exceed  that  degree. 

"I  recommend,  therefore,  that  the  malt  should  be  well  freed  from 
husk,  and  finely  ground;  that  the  wheat  flour  should  be  lightl}'  baked; 
and  finally,  that  a  thermometer  should  be  employed  in  the  preparation 
of  the  food.  Indeed,  in  some  samples  recently  submitted  to  me  by 
Messrs.  Savory  &  Moore,  I  find  that  the  first  two  points  have  been 
attended  to,  and  that  they  use  malt  freed  from  husk  and  finely  ground, 
and  the  wheat  flour  baked. 

"The  eff"ect  of  baking  !the  wheat  flour  is  to  partially  cook  the  starch 
entering  into  its  composition,  so  that  less  heat  is  required  in  the  pre- 
paration of  the  liquid  food.  I  find  that  a  temperature  ranging  between 
140°  and  148°  is  amply  suflficient  to  effect  the  complete  transformation 
and  solution  of  the  starch  corpuscles,  and,  indeed,  to  cook  the  food 
sufl5cientl3\" 

I  have,  in  some  cases,  directed  food  to  be  given  prepared  as  recom- 
mended by  Dr.  Meigs,  but  my  observations  in  reference  to  the  effect  of 
it  have  not  been  sufficient  to  enable  me  to  speak  confidently  in  regard 
to  it.  Gelatine  is  of  little  value  as  a  nutritive  substance,  but  it  is  the 
opinion  of  some  that,  when  combined  with  farinaceous  substances,  it 
renders  them  less  irritating. 

Liebig's  soup  was  prepared  a  few  times  for  the  foundlings  in  the 
Infant's  Service  in  Charity  Hospital.     The  result  did  not  justify  the 


718  APPENDIX. 

expectations  which  had  been  formed  in  consequence  of  the  plausibility 
of  the  theory,  and  the  reputation  of  the  great  chemist.  On  the  first 
day  in  which  it  was  used,  an  unusually  large  number  of  the  foundlings 
were  observed  to  vomit.  The  soup  was  prepared  under  the  supervision 
of  the  matron  of  the  institution.  The  test  was  not  conclusive,  as  it  is 
probable  that  there  was  some  fault  in  the  preparation,  or  in  the  materials 
used.  The  mode  of  preparing  this  soup  is  too  tedious  for  common  use, 
but  it  deserves  trial  in  cases  in  which  the  ordinary  kinds  of  food 
disagree. 

I  have  collected  the  above  formulge  on  account  of  the  great  import- 
ance of  the  use  of  properly-prepared  and  digestible  food  in  the  regimen 
of  infants,  especially  those  that  present  symptoms  of  indigestion. 
Success  in  the  treatment  of  diarrhoeal  affections,  and  of  all  infantile 
diseases  which  are  attended  by  feebleness  of  the  digestive  functions, 
depends  as  much  on  dietetic  as  therapeutic  measures.  The  physician 
should,  therefore,  be  as  familiar  with  dietetic  as  he  is  with  medicinal 
formulae,  that  he  may  use  them  as  occasions  arise. 

The  egg  bears  considerable  resemblance  to  milk  and  to  flesh,  in  its 
chemical  composition,  and  it  is  often  relished  by  infants  and  children. 
It  is  useful  in  states  of  feebleness,  on  account  of  its  highly  nutritive 
properties ;  and,  if  given  nearly  raw,  it  is  easilj'^  digested.  It  should 
not  be  heated  above  130°  Fahr.,  for  a  higher  temperature  coagulates 
the  albumen.  It  may  be  prepared  by  being  placed  in  boiling  water  for 
two  minutes.  This  will  warm  it  sufficiently,  while  only  a  little  of  the 
exterior  of  the  albumen  is  coagulated. 

It  remains  to  speak  of  meat  and  the  meat-broths.  Raw  meat  was 
first  employed  by  Professor  Weisse,  of  St.  Petersburg,  in  the  treatment 
of  infantile  diarrhcea,  consequent  on  weaning.  The  lean  of  beef  or 
mutton  should  be  used,  and  the  finely-divided  portions  removed  by 
scraping,  given  to  an  infant  from  eight  to  twelve  mouths  old  in  quantity 
varjdng  from  one  to  two  teaspoonfuls,  three  or  four  times  in  twenty- 
four  hours.  A  larger  amount  may  be  given,  if  the  infant  wishes  it. 
Raw  meat  prepared  in  this  manner,  or  ver3^  finely  cut,  is  not  only  very 
nutritious,  but  it  sometimes  agrees  better  with  the  digestive  organs  of 
the  infant,  than  any  of  the  preparations  of  milk. 

The  use  of  the  pulp  of  raw  meat  was  introduced  into  the  Children's 
Wards  of  Philadelphia  Hospital  in  1855,  by  Dr.  Caspar  Lewis.  It  was 
seasoned  with  salt,  and  sometimes  sugar  was  added,  to  render  it  more 
palatable.  A  teaspoonful  was  at  first  allowed  three  or  four  times  daily, 
and  the  quantity  was  gradually  increased.  Infants  who  were  suffering 
from  mal-nutrition,  were  found  to  thrive  with  the  use  of  this  food  as  a 
part  of  their  daily  diet.  The  pulp  of  raw  meat  has  been  most  frequently 
employed  in  private  as  well  as  hospital  practice,  in  the  treatment  of  the 
indigestion  and  diarrhoea  of  infants.     Many  infants  reduced  to  a  state 


APPENDIX.  719 

of  feebleness  and  emaciation  gradually  recover  flesh  and  strength  with 
the  use  of  this  diet,  which  is  more  easily  digested,  while  it  is  more 
nutritious,  than  farinaceous  substances  or  cow's  milk.  The  only  danger 
in  the  use  of  raw  moat  is  that  of  producing  trichinosis.  With  care, 
however,  in  selecting  the  meat,  danger  from  this  source  is  slight,  as 
trichinosis  is  a  comparatively  rare  disease.  The  late  Professor  Elliott, 
of  Bellevue  Hospital  Medical  College,  never  failed  to  recommend,  in  his 
lectures,  the  use  of  raw  meat  for  infants  wasted  with  chronic  diseases, 
and  whose  digestive  organs  were  enfeebled. 

Beef-tea,  prepared  in  the  oi-dinary  manner,  by  adding  finely-divided 
meat  to  three  or  four  times  its  bulk  of  cold  water,  allowing  it  to 
macerate  half  an  hour,  and  then  boiling  it  fifteen  or  twenty  minutes,  is 
much  used  for  its  highly  nutritive  properties  in  infantile  diseases,  as 
well  as  a  food  for  healthy  infants.  Given,  however,  in  diarrha3al  affec- 
tions of  infants,  I  have  often  observed  that  it  produced  a  laxative  effect, 
so  that  it  was  necessarj^  to  discontinue  its  use.  The  same  effect,  though 
in  less  degree,  sometimes  occurs  from  the  use  of  mutton  or  chicken-tea, 
in  similar  cases.  Beef-essence  prepared  from  finelj^-chopped  beef,  placed 
dry  in  a  loosely-corked  bottle,  and  standing  three  or  four  hours  in 
boiling  water,  is  a  highly  nutritive  substance.  It  is  the  juice  of  the 
meat  containing  all  those  principles  which  heat  can  extract.  It  is  often 
useful,  given  in  small  quantities,  in  exhausting  diseases,  especially  in 
those  in  which  the  stomach  is  irritable,  and  more  bulky  food  is  rejected. 
Evidently,  the  albumen  of  the  meat  is  coagulated  by  the  heat,  and, 
therefore,  lost. 

Liebig's  beep-tea  is  too  expensive  for  common  use,  but  it  is  a  more 
nutritious  and  better  preparation  than  the  beef-essence.  It  is  prepared 
as  follows :  Finely-divided  beef  is  lixiviated  with  cold  water,  so  as  to 
remove  from  it  all  soluble  substances.  The  solution  is  evaporated  to 
dryness  over  a  sand  bath,  at  a  temperature  of  about  120°.  At  so  low  a 
temperature  neither  the  albumen  nor  the  coloring  matter  is  coagulated. 
The  tea,  which  contains,  unchanged,  nearly  all  the  nutritive  principles 
of  beef,  together  with  the  salts,  may  be  diluted  with  water  at  the  time 
of  its  use. 

Beef-tea  which  has  been  subjected  to  the  action  of  gastric  juice  has 
also  been  recommended.  The  mucous  membrane  of  the  stomach  of 
some  animal  is  macerated  in  water,  to  which  a  little  hydrochloric  acid 
is  added  in  the  proportion  of  three  drops  of  the  strong  acid  to  one 
ounce  of  water.  The  maceration,  which  should  be  at  a  temperature  of 
about  10°  Fahr.,  produces  a  liquid  having  the  solvent  properties  of 
gastric  juice.  Beef-tea  is  prepared  according  to  Liebig's  formula,  and 
then  diluted  with  cold  water.  This  solution  should  remain  a  few  hours 
cold,  and  then  the  artificial  gastric  juice  be  added.  The  fibrin  and 
albuminous  substances  are  digested.     The  product  which  results  has 


720  APPENDIX. 

been  called  artificial  ch3'me.  In  cases  of  deficient  gastric  juice,  or  feeble 
digestive  power  of  the  stomach,  it  is  obvious  that  this  food  may  possess 
decided  advantages. 

Dr.  Ronth  speaks  of  Hogarth's  Essence  of  Meat,  which  is  little 
known  in  this  country  {Infant  Feeding^  page  303).  "Of  the  composi- 
tion," says  he,  "of  this  material  I  can  say  nothing,  except  that  I  believe 
it  is  a  concentrated  solution  of  meat  tea — in  fact,  a  meat  tea  reduced 
by  the  evaporation  of  its  watery  ingredients  to  the  consistence  of  a 
s^a'up.  I  can,  however,  confidently'  speak  from  experience  of  its  utility. 
It  is  certain  that  children  who  have  been  reduced  to  a  state  of  great 
weakness  by  hand-feeding,  or  improper  diet,  occasionally  recover,  and 
that  almost  marvellously,  under  its  influence.  I  have  used  principally 
the  essence  of  beef.  Its  taste  is  much  liked  ;  and  in  doses  of  five  or  six 
teaspoonfuls  daily,  with  a  \&vy  little  water,  it  is  well  digested  by  children. 
Indeed,  it  is  often  borne  in  infants  affected  with  exhaustive  diarrhoea 
from  weaning,  when  milk  and  farinaceous  food  disagree." 

Meat  teas  and  essences,  which  require  so  much  care  and  time  in  their 
preparation  as  those  of  Liebig  and  Hogarth,  are  obviouslj^  to  be 
emploj'ed  only  in  those  cases  in  which  there  is  disease  or  derangement 
of  the  digestive  organs,  or  feebleness  of  the  disestive  function,  so  that 
the  ordinary  kinds  of  food  disagree.  Most  infants  in  good  health  are 
able  to  digest  at  the  age  of  twelve  or  fifteen  months,  when  the  period  of 
weaning  arrives,  those  kinds  of  solid  food  which  are  easily  digested,  if 
well  prepared  and  mashed  or  cut  fine. 

As  regards  the  use  of  farinaceous  food  for  infants  and  young  children, 
barley  flour  properly  boiled  in  milk  or  water  is  as  easily  digested  and 
as  nutritious  as  rice,  or  wheat  flour,  or  arrowroot,  and  in  some  instances 
it  appears  to  agree  better. 

An  article  of  food  emploj'ed  in  this  city  for  the  diarrhoea  of  infants  is 
prepared  as  follows:  A  pound  of  dry  wheat  flour,  of  the  best  quality, is 
packed  snugly  in  a  bag  and  boiled  three  or  four  hours.  When  it  is 
taken  from  the  bag,  it  is  hard,  resembliug  a  piece  of  chalk,  with  the  ex- 
ception of  the  exterior,  which  is  wet  and  should  be  removed.  The  flour 
grated  from  the  mass  should  be  used  the  same  as  arrowroot  or  rice. 


B. 

REMARKS  ON  THE  PREVENTION  OF  SCARLET  FEVER. 

By  Wm.  Budd,  M.D., 

Honorary  and  Consulting  Physician  to  the  Bristol  Royal  Infirmary. 

Much  more,  indeed,  can  be  done  to  limit  the  spread  of  this  malignant 
fever  than  the  public  are  at  all  aware  of,  or  than  the  common  practice 
of  medical  men  generally  would  seem  to  indicate. 


APPENDIX.  721 

There  is  good  reason  to  believe  that  not  onl}'  the  eruption  on  tlie 
skin,  but  everything  that  is  shed  by  the  body  of  the  infected,  is  heavily 
laden  with  the  germs  or  seeds  by  which  (alone,  no  doubt)  the  disease  is 
propagated.  The  discharges  from  the  throat  and  nose  are,  I  imagine, 
especially  virulent.  It  is  more  than  suspected,  on  grounds  on  which  I 
need  not  here  insist,  that  those  from  the  bowel  are  scarcely  less  so.  As 
the  kidney  is  known  to  be  afiected  in  a  very  special,  and  often  in  a  very- 
severe  way,  by  the  poison,  this  organ  probably  furnishes  another  outlet 
for  it.  All  analogy  tends  to  indicate,  indeed,  that  in  this  case  the  renal 
epithelium,  which  is  cast  off  so  plentifull}'-,  performs  the  same  elimina- 
tive  function  as  that  which  is  cast  off  in  still  greater  profusion  by  the 
outer  surface  of  the  body.'  As  the  bulk  of  all  these  excreta  soon  finds 
its  way  to  the  cesspool  or  sewer,  the  large  part  which  sewers  and  cess- 
pools are  known  to  \)\a.y  in  the  dissemination  of  the  fever,  and  which, 
quite  lately  even,  has  been  so  strangely  misinterpreted,  is  easily  under- 
stood. I  could  enlarge  much  on  this  topic,  if  I  had  time  to  do  so.  It 
must  suffice  for  the  present  to  say,  once  for  all,  that  all  that  has  been 
shown  to  hold  of  typhoid  fever  in  regard  to  these  relations — contamina- 
tion of  drinking  water  included — may  be  applied,  with  little  qualification, 
to  scarlet  fever  also. 

Taking  these  things  as  our  data,  the  one  thing  to  aim  at,  therefore, 
in  seeking  to  prevent  the  spread  of  this  fever,  is  to  annihilate  the  germs 
proceeding  from  these  various  sources  on  their  very  issue  from  the 
body,  and  before  the  patient  leaves  the  sick-room.  In  accordance  with 
this  view,  I  have  long  been  in  the  habit,  in  all  cases  which  fall  under 
my  own  care,  of  enforcing  the  following  simple  precautions  : — 

1.  The  room  in  which  the  patient  is  detained  is  dismantled  of  all 
needless  woollen  or  other  draperies  which  might  possibly  serve  to  harbor 
the  poison. 

2.  A  basin,  charged  with  chloride  or  carbonate  of  lime,  or  some  other 
convenient  disinfectant,  is  kept  constantly  on  the  bed,  for  the  patient 
to  spit  into. 

3.  A  large  vessel,  containing  water  impregnated  with  chlorides  or 
with  Condy's  fluid,  always  stands  in  the  room,  for  the  reception  of  all 
bed  and  body  linen,  immediately  on  its  removal  from  the  person  of  the 
patient. 

4.  Pocket-handkerchiefs  are  proscribed ;  and  small  pieces  of  rag  are 
used  instead,  for  wiping  the  mouth  and  nose.  Each  piece,  after  being 
once  used,  is  immediately  burnt. 

5.  As  the  hands  of  nurses  and  of  the  medical  attendant  of  necessity 
become  frequently  soiled  by  the  specific  excreta,  a  good  supply  of 
towels,  and  two  basins,  one  containing  water  with  Condy's  fluid  or 
chlorides,  and  another  plain  soap  and  water,  are  always  at  hand,  for  the 
immediate  removal  of  the  taint. 

4t> 


722  APPENDIX, 

C).  All  glasses,  cups,  or  otlier  vessels,  used  bj^  or  about  the  patient,  are 
scrupulously  cleaned  before  being  used  b}^  others. 

T.  The  discharges  from  the  bowel  and  kidnej'  are  received,  on  their 
very  issue  from  the  body,  into  vessels  charged  with  disinfectants. 

By  these  measures,  the  greater  part  of  the  germs  which  are  thrown 
oft"  by  internal  surfaces  are  robbed  of  their  power  to  propagate  the 
fever.  Those  which  are  thrown  off"  by  the  skin  require  somewhat 
different  management.  If  my  information  do  not  mislead  me,  it  is  in 
dealing  with  these  that  the  practice  of  medical  men  generally  is  most 
defective.  There  are,  no  doubt,  distinguished  exceptions  ;  but  for  the 
most  part,  either  nothing  is  done,  or  what  is  done  is  done  imj^erfectly 
or  too  late.  And  yet  to  destroy  from  the  first,  as  far  as  possible,  the 
infectious  power  of  what  emanates  from  the  skin,  is,  for  obvious  reasons, 
the  most  important  object  of  all  in  the  way  of  prevention. 

In  the  first  place,  as  the  skin  is  at  once  the  most  extensive  surface  of 
the  body,  and  is,  par  excellence,  the  seat  of  what,  b}^  a  very  just  figure, 
is  called  the  eruption,  the  crop  of  new  poison  which  escapes  by  the  skin 
probably  far  exceeds  in  amount  that  which  escapes  by  the  other  surfaces. 
It  is  impossible  to  speak  in  exact  figures  here.  We  cannot  count  these 
things  as  we  count  peas,  or  beans,  or  grains  of  wheat.  But  the  care  of 
smallpox  furnishes  us  with  a  standard  which  cannot  far  mislead  us. 
And,  as  we  know  that,  in  a  case  of  confluent  smallpox,  enough  new 
poison  is  thrown  off  actually  to  inoculate  with  smallpox  myriads  of 
others,  so  there  is  every  reason  to  believe  that  the  skin-crop  in  a  severe 
case  of  scarlet  fever  is  little,  if  at  all,  less  prolific. 

In  the  next  place,  as  the  process  of  desquamation,  by  which  this  crop 
is  finally  cast  loose,  is  a  ver}'-  slow  one — lasting,  for  the  most  part,  over 
many  weeks — the  infection  from  this  source  is  much  more  abiding  than 
that  from  the  internal  sources.  But  what  renders  it  still  more  so  is  the 
all-important  fact  that  the  poison  which  is  liberated  by  the  skin  is 
liberated  in  the  dried  state.  It  is  well  known — and,  indeed,  the  circum- 
stance has  been  taken  advantage  of  in  the  practice  of  inoculation  by 
cowpox  and  other  poisons — that  animal  poisons,  when  dried  at  a  gentle 
heat,  retain  their  powers  for  quite  indefinite  periods  of  time.  But  to 
be  dried  at  a  gentle  heat — a  heat  lower  in  fact  than  that  which  attended 
its  own  generation — is  precisely  the  case  of  the  scarlet  fever  poison,  as 
cast  off"  by  the  skin. 

Another  danger  is  created  by  the  minute  and  impalpable  form  in 
which  the  particles  armed  with  the  poison  are  set  free.  The  skin  peels 
oft'  in  part,  no  doubt,  in  flakes  of  palpable  size,  but  in  still  greater  part, 
under  the  guise  of  dust,  which  floats  in  the  air,  impalpable  like  motes  in 
the  sunbeam.  Each  of  these  little  atoms  is,  potentiall}',  the  scarlet  fever. 
While  the}'-  adhere  to  the  body,  the}^  may  be  readily  disarmed;  but  once 
.afloat,  they  are  in  great  degree  beyond  our  power. 


APPENDIX.  72 


It  is  to  these  various  circumstances — to  the  countless  profusion  of 
the  new  seed,  if  I  may  so  speak,  which  is  generated  and  sown  broadcast 
bj'  every  fresh  case — to  the  length  of  time  during  which  it  hangs  about 
the  sick,  capable  every  moment  of  being  transferred,  with  all  its  deadly 
power,  to  thing  or  person — to  the  impalpable  minuteness  of  the  organic 
particles  in  which  this  seed  is  iniV)cddcd — and,  lastly,  to  the  long  reten- 
tion of  their  properties,  in  virtue  of  being  in  the  dried  state — that  we 
must  look  mainly  for  the  true  explanation  of  the  well-known  subtleness 
and  tenacity  of  this  particular  infection.  To  the  many  striking  illus- 
trations of  this  subtlety  and  tenacity  on  record,  I  could,  if  there  were 
need,  add  many  of  my  own,  quite  as  striking,  and  free  from  all 
ambiguity;  but  it  is  a  waste  of  time  and  space  to  burden  the  page  with 
what  is  already  conceded,  and  with  what  most  men  must  be  sufficiently 
familiar. 

These  same  circumstances  are  the  source  of  the  peculiar  embarrass- 
ment and  perplexit3%  which,  in  scarlet  fever,  hang  over  the  disposal  of 
the  convalescent,  and  the  period,  so  much  debated,  and  at  present  con- 
fessedly undetermined,  at  which  he  may  be  safely  restored  to  society. 

According  to  my  own  experience,  these  difficulties  and  perplexities 
may  be  entirely  averted  by  the  employment  of  the  simplest  precautious. 
To  be  successful,  these  precautions  must  be  put  in  force  earlj^,  and  must 
be  thoroughl}'  carried  out.  The  first  thing  to  aim  at,  is,  to  prevent  the 
minute  particles,  which  are  the  carriers  of  the  poison,  from  taking  wing, 
until  they  can  be  disenfected  in  situ.  This,  I  find,  can  be  perfectly 
effected  by  simply  anointing  the  surface  of  the  bod^^,  scalp  included, 
twice  a  day  with  olive  oil.  The  oil  I  use  is,  generally,  slightly  impreg- 
nated with  camphor.  As  far  as  the  main  object  is  concerned,  the 
addition  is  perhaps  unimportant;  but  it  is  agreeable  to  the  patient,  and 
probably  has  some  part  in  the  relief,  which  almost  always  follows  the 
inunction,  from  the  troublesome  itching,  which  is  a  well-known  incident 
of  some  stages  of  the  disorder.  Current  views  would,  perhaps,  indicate 
carbolic  acid  as  a  fitter  adjunct;  but,  having  found  the  camphorated  oil 
to  answer  perfectly,  I  have  thought  it  tl>e  part  of  wisdom  to  make  no 
change.  I  may  add,  that  the  process,  so  far  from  being  trying,  is  very 
soothing  to  the  sick;  and,  if  it  exert  any  influence  at  all  on  the  evolu- 
tion of  the  disorder,  this  influence  appears  to  be  beneficial  rather  than 
otherwise.  The  precise  period  at  which  it  should  be  begun  varies 
somewhat,  no  doubt,  in  different  cases.  As  early  as  the  fourth  day  of 
the  eruption,  a  white  efflorescence  may  often  be  observed  on  the  skin  of 
the  neck  and  arms,  which  marks  the  first  liberation  of  the  new  death- 
giving  brood.  This  efflorescence  should  be  made  the  signal  for  the  first 
employment  of  the  oil.  From  this  time,  the  oiling  is  continued  until 
the  patient  is  well  enough  to  take  a  warm  bath,  in  which  the  whole 
person — scalp  again  included — is  well  scrubbed,  disinfecting  soap  being 


72-i  APPENDIX. 

abundantl}^  used  during  the  process.  These  baths  are  repeated  every 
other  day,  until  four  have  beeu  taken,  when,  as  far  as  the  skin  is  con- 
cerned, the  disinfection  may  be  regarded  as  complete.  If  the  health  be 
quite  recovered — if,  in  particular,  there  be  no  disease  of  kidney  and  no 
discharge  from  throat  or  nostril — the  patient  (equipped,  of  course,  in  a 
new  or  perfectly  untainted  suit)  may  generally  be  restored  without  risk 
to  his  famil}'.  A  week  or  ten  days'  additional  quarantine  is,  however, 
seldom  objected  to;  and  is,  on  the  whole,  perhaps  more  prudent.  Many 
medical  men  are  in  the  habit  of  fumigating  the  sick-room,  either  con- 
stantly or  several  times  a  da}^,  with  chlorine  or  sulphurous  acid,  pending 
the  whole  course  of  the  fever.  There  can  be  no  objection  to  this 
measure;  but  I  do  not  myself  attach  much  importance  to  it.  Experience 
of  the  largest  and  most  decisive  kind  has  shown  that  chlorine — and  I 
believe  the  observation  applies  equally  to  the  other  chemical  agent — in 
the  degree  of  atmospheric  impregnation  respirable  by  man,  has  no 
appreciable  influence  in  preventing  the  spread  of  infectious  disorders. 
To  complete  the  preventive  code,  immediately  after  the  illness  is  over — 
whether  ending  in  death  or  recover}^ — the  dresses  worn  by  the  nurses 
(which,  where  possible,  should  be  of  linen,  or  some  smooth  thing)  are 
washed  or  destroyed,  and  the  bed  and  room  that  have  been  occupied  by 
the  sick  are  thoroughly  disinfected.  With  these  measures,  when  well 
and  thoroughly  done,  the  taint  is  finally  extinguished.  ThQ  success  of 
this  method,  in  my  own  hands,  has  been  ver}-  remarkable.  For  a  period 
of  nearly  twenty  j^ears,  during  which  I  have  employed  it  in  a  ver^'^  wide 
field,  I  have  never  known  the  disease  to  spread  in  a  single  instance 
])eyond  the  sick-room,  and'  in  very  few  instances  within  it.  Time  after 
time  I  have  treated  this  fever  in  houses  crowded  from  attic  to  base- 
ment, with  children  and  others,  who  have  nevertheless  escaped  infection. 
The  two  elements  in  the  method  are,  separation  on  the  one  hand,  and 
disinfection  on  the  other.     (British  Medical  Journal,  Jan.  9th,  1869.) 

The  Health  Board  of  ^S'ew  York  enforce  the  following  Sanitary 
Reg-ulations  against  Scarlatina  and  Measles: — 

Every  case  must  be  reported  to  the  City  Sanitary  Inspector  upon  its 
first  recognized  appearance. 

Care  of  Patients. — The  patient  should  be  placed  in  a  separate  room, 
and  no  person  except  the  phj'sician,  nurse,  or  mother,  allowed  to  enter 
the  room,  or  to  touch  the  bedding  or  clothing  used  in  the  sick-room, 
until  ih&y  have  beeu  thoroughly  disinfected. 

Infected  Articles. — All  clothing,  bedding,  or  other  articles  not 
absolutely  necessary-  for  the  use  of  the  patient,  should  be  removed  from 
the  sick-room.  Articles  used  about  the  patient,  such  as  sheets,  pillow 
cases,  blankets,  or  clothes,  must  not  be  removed  from  the  sick-room 
until  they  have  been  disinfected,  by  placing  them  in  a  tub  witli  the 
following  disinfecting  fluid:  eight  ounces  of  sulphate  of  zinc,  one  ounce 
of  carbolic  acid,  three  gallons  of  water. 


APPENDIX.  725 

ThcN''  should  be  soaked  in  this  fluid  for  at  least  one  hour,  and  then 
placed  in  boiling  water  for  washing. 

A  piece  of  muslin,  one  foot  square,  should  be  dipped  in  the  same 
solution  and  suspended  in  tlie  sick-room  constantly,  and  the  same  should 
be  done  in  the  hallway  adjoining  the  sick-room. 

Feather  l)eds  and  pillows,  liair  pillows  and  mattresses,  and  flannels  or 
woollen  goods,  require  fumigation,  and  should  not  be  removed  from  the 
sick-room  until  after  this  has  been  done.  Whenever  the  patient  is 
removed  from  the  sick-room,  notify  the  Bureau  of  Sanitary  Inspection, 
when  the  disinfecting  corps  will  as  soon  as  possible  thereafter  perform 
the  work  of  fumigation. 

All  vessels  used  for  receiving  the  discharges  of  patients  should  have 
some  of  the  same  disinfecting  fluid  constantly  therein,  and  immediately 
after  use  by  the  patient  be  emptied  and  cleansed  with  boiling  water. 
Water  closets  and  privies  should  also  be  disinfected  daily  with  the  same 
fluid,  or  a  solution  of  chloride  of  iron,  one  pound  to  a  gallon  of  water, 
adding  one  or  two  ounces  of  carbolic  acid. 

All  straw  beds  should  be  burned,  but  must  not  be  removed  from  the 
sick-room  without  a  permit  from  this  department.  They  will  be  removed 
by  the  disinfecting  corps. 

It  is  advised  not  to  use  handkerchiefs  about  the  patient,  but  rather 
soft  rags  for  cleansing  the  nostrils  and  mouth,  which  should  be  imme- 
diatel}'"  thereafter  burned. 

The  ceilings  and  side  walls  of  the  sick-room  after  removal  of  the 
patient  should  be  thoroughly  cleaned  and  lime  washed,  and  the  wood- 
work and  floor  thorougly  scrubbed  with  soap  and  water. 


C. 

REMARKS  ON  THE  DIPHTHERITIC  MEMBRANE. 

By  Dr.  Edward  Rindfleisch, 

Professor  of  Pathological  Anatomy  in  Bonn. 

Genuine  diphtheritis  has  no  claim  to  be  regarded  as  a  specific  process 
in  the  same  measure  as  croup.  That  which  microscopically  characterizes 
it,  and  has  become  the  occasion  of  placing  it  as  a  membranous  inflam- 
mation by  the  side  of  the  pseudo-membranous  inflammation,  is  the 
formation  of  a  whitish-graj',  often  discolored  by  reddish  and  green 
(blood-coloring  matter)  tints,  compact,  felted  membrane,  which  is  ele- 
vated, perhaps,  to  the  height  of  one-half  line  alone  the  level  of  the 
mucous  membrane,  but  penetrates  just  as  deep  into  the  substance  of 
the  mucous  membrane,  and  is  most  intimately  connected  with  the  latter. 
This  membrane  is  nothing  that  is  superimposed,  nothing  secreted,  but 


726  APPENDIX. 

the  mucosa  itself,  as  far  as  it  has  been  partly  tumefied,  partly  rendered 
anosraic,  even  by  the  excessive  infiltration  with  cells.  This  condition 
has  not  improperly  been  compared  with  a  mortification  by  a  chemical 
agent,  with  a  corrosion,  and  the  diphtheritic  membrane  has  been  desig- 
nated as  diphtheritic  scab  ;  in  fact  the  diphtheritic  membrane  is  a  caput 
mortuum,  it  can  undergo  no  other  changes  than  those  of  putrefaction, 
of  decomposition ;  and  the  question  only  is,  how  it  is  loosened  and 
removed  from  the  intimate  organic  connection  in  which  it  stands  with 
the  mucous  membrane.  A  sharply  defined  boundary  line  separates,  as 
we  can  convince  ourselves  with  the  naked  ej'e,  the  living  from  the  dead  ; 
but  numerous  connective-tissue  fibres,  bloodvessels,  nerves,  and  elastic 
fibres,  pass  over  from  the  living  into  the  dead ;  they  must  all  have 
separated  ere  the  loosening  can  proceed.  The  means  which  are  placed 
at  the  command  of  the  organism  are  inflammation  and  suppuration. 
We  call  this  inflammation  "reactive,"  and  unite  with  it  the  idea  as 
though  this  were  an  answer  to  the  irritation,  which  the  diphtheritic  scab 
exerts  upon  the  surrounding  mucous  membrane;  yet  a  portion  of  the 
hyperemia  also  may  be  explained  according  to  static  principles  as 
collateral  fluxion.  The  pus  collects  between  the  scab  and  the  healthy 
parts  and  always,  accordingly  as  the  fibrous  bridges  mentioned  melt 
down  and  tear,  the  separation  begins  now  at  the  edges,  then  at  the 
centre.  After  it  is  completed  an  ulcer  remains  behind  which  is  disposed 
to  rapid  cicatrization  ;  not  unfrequently,  however,  the  process  repeats 
itself  again  at  the  same  place ;  we  have  a  new  scab,  and  with  it  anew 
the  necessity  of  a  purulent  separation,  after  whose  termination  a  very 
considerable  loss  of  substance  remains.  The  cicatrices  finally  resulting 
distinguish  themselves  by  their  capacit}'^  of  vigorous  retraction,  so  that 
the  danger  of  subsequent  contraction  of  mucous  membrane  canals, 
especially  of  the  large  intestine  after  dj^sentery,  threatens  so  much  the 
more,  the  more  diff'used  the  ulceration  was.  (^Text-hook  of  Pathological 
Histology,  translated,  page  354.) 


E. 

The  following  observations  relate  to  the  state  of  the  liver  in  that 
form  of  infantile  entero-colitis  which  prevails  in  the  summer  months, 
especially  in  the  cities.  They  were  made  in  order  to  determine  the 
correctness  or  falsity  of  a  prett}'^  general  belief  on  the  part  of  city 
practitioners,  arising  probably  from  the  frequent  green  appearance  of 
the  stools,  that  the  function  of  the  liver  is  perverted,  and  the  bile  there- 
fore unhealth}',  in  this  disease.  These  observations  are  sufficiently 
numerous,  in  my  opinion,  to  prove  that  mercurial  or  other  treatment 


ArrEN])ix.  727 

designed  to  modify  or  correct  the  function  of  this  organ  is  not  justified 
by  the  anatornicid  characters  of  the  disease. 

Juno  8,  1850.  Aij^c'd  5  months;  duratinii  of  sickness,  G  days.  Liver  appeared 
liealtliy;  about  the  usual  size. 

June  8,  1850.  A_<,n'd  :!  uionlhs;  duration  of  sickness,  20  days.  Liver  of  usual 
size  and  color ;  it  contained  tiic  usual  amount  of  oil  globules;  from  one  to  six  or 
eight  globules  in  each  hepatic  cell. 

June  10,  1850.  Aged  4  months;  duration  of  sickness,  5  days.  Liver  of  ordinary 
appearance;  contains  rallier  less  fatty  matter  than  usual;  few  hepatic  cells  con- 
tained nu)re  than  tive  or  six  oil  glolMilcs. 

July  4,  1850.  Agetl  7  nu)nths  ;  duration  of  sickness,  3  weeks.  Liver  of  yellower 
hue  than  natural ;  not  enlarged;  the  oil  globules  considerably  exceeded  the  usual 
amount. 

July  10,  1850.  Aged  0  weeks  ;  duration  of  sickness,  3  weeks.  Liver  small  and 
almost  destitute  of  oil  globnles  ;  nine-tentlis  of  the  hepatic  cells  (iontained  none. 

August  8,  1850.  Aged  7  months  ;  duration  of  sickness,  1  month.  Liver  appeared 
healthy;  weighing  oz.  iv. 

August  15,  1859.  Aged  19  months  ;  duration  of  sickness,  several  weeks.  Liver 
extended  half  an  inch  below  the  margin  of  tlie  ribs ;  weighed  oz.  ix  ;  but  few  oil 
glob\iles  in  most  of  the  hepatic  cells  ;  a  few  contained  numerous  small  glo1)ules. 

August  15,  1859.  Aged  15  months  ;  duration  of  sickness,  2  months.  Liver  of 
usual  appearance  ;  weight,  oz.  vijss  ;  nothing  unusual  observed  in  this  organ  under 
the  microscope. 

August  15,  1859.  Aged  14  mouths  ;  duration  of  sickness,  3  weeks.  Liver 
weiglied  oz.  ix ;  its  appearance  natural  both  to  the  naked  eye,  and  under  the 
microscope. 

August  17,  1859.  Aged  15  montlis  ;  duration  of  sickness,  several  weeks.  Liver 
appeared  healtliy ;  weight,  oz.  vj. 

August  22,  1859.  Liver  of  normal  appearance;  it  contained  the  usual  amount 
of  oil  globules;  weight,  oz.  viij. 

August  27,  1859.  Aged  0  months.  Liver  of  natural  color  generally,  but  yellow 
in  places ;  weight,  oz.  viij  ;  no  more  than  the  usual  amount  of  fatty  matter  dis- 
covered by  the  microscope. 

August  31,  1859.  Aged  5  months  ;  duration  of  sickness,  at  least  one  month. 
Surf^ice  of  liver  mottled  of  a  yellow  color ;  no  excess  of  oil  globules  generally ; 
weight  of  liver,  oz.  vjss. 

September  4,  1859.  Aged  2  months  ;  duration  of  sickness,  one  week.  Liver  of 
normal  appearance ;  few  hepatic  cells  contained  more  than  four  oil  globules  and 
many  contained  none  ;  little  free  oily  matter. 

September  5,  1850.  Age  16  months.  Liver  small ;  weighing  oz.  vj,  and  con- 
taining very  little  oily  matter. 

September  15,  1859.  Aged  23  months  ;  duration  of  sickness,  all  summer.  Liver 
quite  fatty  ;  weighing  oz.  xv  ;  had  tuberculosis. 

July  3,  1860.  Aged  13  months  ;  duration  of  sickness,  nearly  one  month.  Liver 
of  yellow  color ;  weight,  oz.  vj  ;  hepatic  cells  contained  somewhat  more  than  the 
usual  oily  matter. 

July  3,  1860.  Aged  4  weeks.  Liver  extended  two  inches  below  the  ribs ;  weight, 
■oz.  V  ;  contained  few  oil  globules. 

August  4,  1860.  Duration  of  sickness,  2  weeks.  Liver  weighed  oz.  ix ; 
mottled  yellow  ;  very  fatt3^ 

August  7,  1860.  Aged  2  months  ;  duration  of  sickness,  10  days.  Anterior  bor- 
der of  liver  even  with  the  margin  of  the  ribs  ;  weight,  oz.  iijss  ;  usual  color  ;  very 
few  oil  globules,  free  or  in  the  heijatic  cells. 

August  8,  1860.  Aged  2  years.  Liver  mottled  with  yellow,  evidently  fatty  spots 
or  patches. 

August  17,  1800.  Liver  extended  half  an  inch  below  the  lower  margin  of  the 
ribs ;  of  usual  color ;  weight,  oz.  v. 

August  30,  1860.  Aged  5  months ;  duration  of  sickness,  1  week.  Liver 
extended  half  an  inch  below  the  margin  of  the  ribs  ;  rather  yellow  ;  weight,  oz.  ix  ; 
numerous  oil  globules,  both  free  and  in  the  hepatic  cells. 

July  18,  1861.  Liver  about  the  usual  size  and  appearance,  except  that  the  color 
is  lighter  in  some  places  than  in  others. 

August  1,  1861.  Aged  2  months;  dui'ation  of  sickness,  about  1  week.  Liver 
small  and  very  dark  ;  the  microscope  showed  it  to  be  almost  destitute  of  oily  matter. 


728  APPENDIX. 

Axignst  12,  1861.  Aged  3i  months.  Anterior  margin  of  liver  even  with  the 
ribs  ;  weight,  oz.  vss. 

August  19,  1861.  Aged  15  months.  "Weight  of  liver,  oz.  ixss ;  contained  the 
normal  amount  of  fat. 

August  21,  1861.  Aged  a  few  months.  Liver  of  usual  appearance  ;  weight  oz. 
iijss. 

October  9,  1861.  Aged  20  months;  duration  of  sickness,  all  summer.  Liver 
rather  j-ellow,  but  not  uniformly ;  weight,  oz.  ix  ;  some  hepatic  cells  free  from  fat ; 
others  loaded  with  it. 

July  7,  1862.  Aged  4  months;  duration  of  sickness,  several  weeks.  Weight  of 
liver,  'oz.  v ;  yellow,  very  fatty. 

August  27,  1862.  Aged  7  months;  duration  of  sickness,^ several  weeks.  Liver 
examined  bv  the  microscope  seemed  healthy  ;  weight,  oz.  vi:^. 

August  29,  1862.  Aged  10  months ;  duration  of  sickness,  1  week.  Weight  of 
liver,  oz.  vif^ ;  appeared  healthy,  except  an  increase  in  the  amount  of  oil  globules. 


F. 

INTUSSUSCEPTION  IN  SMALL  INTESTINE. 

No.  1.  Aged  12  years.  Had  pain  in  abdomen  two  or  three  weeks  previously. 
Died  the  fifth  day.  Twelve  inches  of  the  upper  part  of  the  jejunum  invaginated 
in  the  next  twelve  inches  below.  (M.  R.  Trevor,  Amer.  Journ.  Med.  Sci.,  Jan. 
1852.) 

No.  2.  Aged  3  years.  Previous  health  not  stated.  Died  the  second  day.  At 
about  the  junction  of  the  jejunum  and  ileum,  twenty-six  inches  of  intestine  had 
been  received  into  six  inches.    (Isaac  Thomas,  M.D.,  Amer.  Med.  Recorder.  1823.) 

No.  3.  Aged  4^  months.  Previous  health  good.  Died  the  fourteenth  day. 
Locality  of  disease,  upper  part  of  ileum  ;  the  mass  Avas  two-thirds  of  an  inch  long. 
(Dr.  J.  L.  Smith,  Amer.  Med.  Times,  July  18, 1863.) 

No.  4.  Aged  4  months.  Had  entero-colitis  previously  to  and  during  the  intus- 
susception. Four  invaginations  in  the  jejunum,  each  from  one  to  one  and  a  half 
inches  in  extent.     (Records  of  N.  Y.  Infant  Asylum,  July  18, 1803.) 

INTUSSUSCEPTION  0^  ILEUM  INTO  COLON. 

No.  5.  Age  not  stated.  Had  previously  constipation,  followed  by  diarrhoea  and 
convulsions.  Died  on  the  fifth  day.  Two  inches  of  the  ileum  projected  into  the 
ccecum.     (Dr.  Mayne,  Path.  Soc.  Dublin,  March  16,  1839.) 

No.  6.  Aged  2  years.  Previously  well.  Died  the  second  day.  About  three 
inches  of  the  Ileum  Inverted  had  passed  through  the  ileo-coecal  valve  into  the  colon. 
(Dr.  Coggswell,  Lond.  Lane,  July,  1853.) 

No.  7.  Aged  4  years.  Previously  well,  except  slight  diarrhoea.  Died  the  tenth 
day.  Thirteen  inches  of  the  ileum  had  passed  through  the  ileo-ccecal  valve  into 
the  coecum.     (Mr.  Filleter,  Lond.  Lane,  May,  1855.) 

No.  8.  Aged  3  years.  Previous  health  not  given.  Died  after  seven  days.  At 
least  a  foot  of  the  ileum  had  passed  through  the  ileo-coecal  valve.  (Mr.  Nunnelly, 
Path.  Soc.  London,  ]\rarch  20,  1860.) 

No.  9.  Aged  4  months.  Previous  health  good.  Died  after  six  weeks.  The 
ileum,  still  adherent,  had  passed  through  the  entire  colon,  so  as  to  protrude  six 
inches  beyond  the  anus.     (S.  Jones,  Lond.  Path.  Soc,  1857.) 

No.  10.  Aged  6  months.  Previously  well.  Died  the  third  day.  The  ileum  had 
passed  through  the  ccecum  and  into  the  ascending  colon.  (Dr.  Cotting,  Bost.  Soc. 
for  Med.  Improvement,  July,  1852.) 

No.  11.  Aged  4  years  and  9  months.  Had  a  cough,  and  since  the  age  of  eigh- 
teen montlis,  tliread  worms;  was  annoyed  by  these  tiie  day  before  the  sickness. 
Died  the  fiftli  day.  Seven  inches  of  the  ileum  had  passed  through  the  ileo-ca?cal 
valve.     (Dr.  Hare,  Lond.  Path.  Soc,  October  16,  1848.) 


APPENDIX.  729 


INVAGINATION  OF  THE  CCECUM,  ILEUM  AND  CCECUM,  Oil 
ILEUM,  C(ECUM,  AND  COLON. 

No.  13.  Aged  5  months.  Previous  health  good.  Died  the  fifth  day.  Six  inches 
of  the  ileum  and  the  ascending  colon  were  invaginated  in  the  sigmoid  flexure  and 
rectum.      (Thomas  lUi/ard,  IMed-Ciiir.  Trans.,  vol.  i.) 

No.  13.  Aged  4  months.  Previous  health  good.  Lived  more  than  one  week. 
A  small  portion  of  the  ileum  and  the  entire  colon  to  the  sigmoid  flexure,  Avere 
iml)edded  in  the  latter.     (Alfred  Markwick,  Lond.  Lane.,  1846.) 

No.  14.  Aged  1  year.  Diarrha\a  previously.  Died  on  the  seventh  day.  A 
portion  of  the  ileum  with  the  co'cum  invaginated  in  the  ascending  and  transverse 
colon.     (Di-.  O'Ferrall,  Lond.  Med.  Times,  January  1(5,  1847.) 

No.  15.  Aged  G  months.  Previous  health  good.  Died  the  third  day.  Several 
inches  of  the  ileum,  the  ccecum,  the  ascending  and  the  transverse  colon,  were 
lodged  in  the  remainder  of  the  transverse  and  in  the  descending  colon.  (Chas. 
Clarke,  Lond.  Lane,  August  18,  1849.) 

No.  10.  Aged  4  months.  Previous  health  good.  Died  the  third  day.  Lower 
part  of  the  ileum,  the  coecum,  ascending  colon,  and  greater  part  of  the  transverse 
were  imbedded  in  the  descending  portion.  (E.  Y.  Steele,  Lond.  Lane,  June  23, 
1849.) 

No.  17.  Aged  4  months.  Sick  two  days  previously.  Died  the  third  day. 
Ca?cum  and  ascending  colon  invaixinated  in  the  transverse  and  descending  colon. 
(P.  P.  Nind,  Lond.  Lane,  June  23,  1849.) 

No.  18.  Aged  20  months.  Previous  health  not  stated.  Died  on  the  fourth  day. 
Six  or  seven  inches  of  the  lower  portion  of  the  ileum,  the  ccecum,  and  the  ascending 
colon  were  filled  with  inverted  intestine  ;  the  six  or  seven  inches  of  the  ileum  were 
drawn  together  so  as  to  measure  only  one  inch,  and  this  part  of  the  ileum  had 
formed  a  second  invagination  in  the  ccecum  to  the  extent  of  two  inches.  (Mr. 
Ta.ylor,  Loud.  Lane.,  1843.) 

No.  19.  Aged  4  years.  Previous  health  not  stated.  Lived  three  days.  Lower 
part  of  the  ileum  and  the  entire  colon  were  invao'inated  in  the  rectum.  (W.  S. 
Partridge,  Prov.  Med.  and  Surg.  Jouru.,  May  3,  1848.) 

No.  20.  Aged  5  months.  Previous  health  not  stated.  About  one  inch  of  the 
ileum  and  the  entire  colon  to  the  left  hypochoudrium  were  lodged  in  the  remaining 
portion  of  the  colon  and  in  the  rectum.  (R.  Harlan,  M.D.,  F.R.S.,  Med.  and 
Phys.  Researches.) 

No.  21.  Aged  6  years.  Diarrhoea  and  pain  in  abdomen.  The  caput  coli  and 
the  first  half  of  the  colon  had  descended  through  the  other  half  and  the  rectum  ; 
the  lower  part  of  the  ileum  was  drawn  down  through  the  centre  of  the  iutusus- 
ceplion  to  the  anus.     (Mr.  Davis,  Med.  Repos.,  December,  1824.) 

No.  23.  Aged  9  months.  Had  occasional  diarrhoea.  Died  the  third  day.  A 
considerable  portion  of  the  ileum  and  the  caput  coli  had  been  forced  up  the  ascend- 
ing colon,  across  the  transverse  and  down  to  the  rectum.  (H.  Cunningham,  Lond. 
Med.  Gaz.,  September  15,  1838.) 

No.  23.  Aged  4  months.  Previous  health  not  given.  Died  the  fourth  day. 
Lower  portion  of  the  ileum,  the  ascending  cohm,  and  a  part  of  the  transverse  colon 
were  invaginated  in  the  remaining  portion  of  the  colon  and  the  rectum.  (Alex. 
Munro,  Path.  Anat.  of  the  Aliment.  Canal.) 

No.  24.  Aged  4  mouths.  Previous  health  good.  Died  the  third  day.  Ccecum 
and  ascending  colon  were  lodged  in  the  transverse  and  beginning  of  the  descending 
portions :  in  the  interior  of  the  mass  was  a  second  invagination,  that  of  the  ileum. 
(Dr.  Ryan,  Med.  Soc.  of  Lond.,  October  27.  1835.) 

No.  25.  Aged  4  months.  Previous  health  good.  Died  the  second  day.  Part 
of  the  ileum  and  cn:>cum  and  a  considerable  portion  of  the  colon  were  invaginated. 
(Evory  Kennedy,  Dub.  Jouru.  of  Med.  Sci.,  March  1,  1844.) 

No.  86.  Aged  7  months.  Previous  health  good.  Died  the  third  day.  Part  of 
the  ileum  and  the  coecum  had  descended  through  the  colon  and  rectum  to  within 
half  an  inch  of  the  anus.     (Dr.  Buchanan,  Lond.  Path.  Soc,  Maj'  3, 1859.) 

No.  27.  Aged  6  months.  Previous  health  good.  Died  the  fifth  day.  A  part  of 
the  ileum  and  the  whole  upper  portion  of  the  large  intestines  were  inclosed  in  the 
descending  colon  and  the  rectum,  to  within  two  inches  of  the  anus.  (Mr.  Ballard, 
Lond.  Path.  Soc,  January  6,  1857.) 

No.  28.  Aged  3  months.  Previous  health  good.  Died  the  third  day.  Part  of 
the  ileum  and  the  ascending  and  transverse  colon  were  lodged  in  the  'descending 
colon.     (J.  W.  Perriu,  Lancet,  March  26, 1853.) 


730  APPENDIX. 

No.  29.  Aged  3  months.  Previous  health  not  stated.  Died  the  first  day.  A 
large  part  of  the  ileum,  the  ascending  and  transverse  colon  were  iuvaginated  in 
the  descending  portion.     (M.  Judson,'Gaz.  Med.,  Decembre,  1837.) 

No.  30.  Aged  3i  years.  Almost  constant  pain  in  the  bowels  for  three  months 
before  death.  The  coecum  and  entire  colon,  to  within  eleven  inches  of  the  anus, 
were  invaginated  in  the  remainder  of  the  colon  and  in  the  rectum.  The  inclosed 
intestine  protruded  five  or  six  inches  beyond  the  anus.  (M.  Robin,  Mem.  de 
I'Acad.  Roy.  de  Chirurg.,  1784.) 

No.  31.  Aged  4  years.  Had  dysentery  previously.  Died  after  sickness  of  nearly 
a  month.  The  ascending  and  transverse  colon  were  found  in  the  sigmoid  flexure 
and  rectum  ;  the  ileum  extended  uninverted  through  the  whole  mass.  (John  C. 
Lettsom.  M.D.,  F.R.S.) 

No.  32.  Aged  9  months.  Previous  health  delicate,  but  without  disease.  Died 
the  second  day.  Six  inches  of  the  ileum,  the  ascending  and  transverse  colon  lay 
within  the  descending  colon  and  the  rectum.  (Mr.  Young,  Brit.  Med.  Jouru., 
September  24,  1859.) 

No.  33.  Aged  lU  months.  Previous  health  not  stated.  Died  the  third  day. 
About  four  inches  oT  the  ileum,  the  ascending  and  transverse  colon,  were  invagi- 
nated in  the  descending  colon.     (Mr.  Clarke, "Lond.  Lane,  February  17,  1838.) 

No.  34.  Aged  6  months.  Previous  health  not  stated.  Died  the  eighth  day. 
The  coecum,  ascending  and  transverse  portions  of  the  colon  were  invaginated  in 
the  descending  colon.     (E.  Smith,  Lond.  Path.  Soc,  December  4,  1848. 

No.  35.  Aged  4  months.  Previous  health  good.  Died  in  nineteen  hours.  Lower 
portion  of  the  ileum  incarcerated  in  the  ascending  colon,  which  was  also  invaginated 
in  the  arch.     (Mr.  Gorham,  Guy's  Hosp.  Reports,  October,  1838.) 

No.  36.  Aged  3  months  and  4  days.  Previous  health  good.  Died  on  the  eighth 
day.  Twelvd  inches  of  the  ileum  doubled  on  itself  had  descended  the  whole 
length  of  the  colon,  so  as  to  protrude  from  the  anus;  colon  drawn  together,  the 
mass  occupying  less  than  a  Toot.    (Dr.  J.  L.  Smith,  N.  Y.  Path.  Soc,  June,  1801.) 

No.  37.  Aged  3  years  and  4  months.  During  two  years  before  death  complained 
of  pain  in  abdomen.  The  coecum  was  inverted,  and  had  descended  to  the  lower 
portion  of  the  rectum.  (Wilmer  Worthington,  M.D.,  Amer.  Journ.  of  Med.  Sci., 
January,  1849.) 

No.  38.  Aged  10  months.  Previous  health  good,  except  liability  to  constipation. 
Lived  two  days.  A  double  intussusception  ;  the  inferior  portion  of  the  ascending 
colon  was  invaginated  in  the  superior,  and  the  whole  again  invaginated  in  the 
transverse  colon.     (Dr.  Blake,  Prov.  Med.  and  Surg.  Journ.,  May  3,  1848.) 

No.  39.  Aged  11  years.  Previous  health  not  stated.  Recovered.  On  the  sixth 
day,  the  caput  coli  and  a  portion  of  the  colon,  with  the  meso-colon,  measuring 
thirteen  and  three-fourths  inches,  were  passed  fi-om  the  bowels.  (J.  W.  Bowman, 
Edin.  Med.  and  Surg.  Journ.,  October,  1813.) 

No.  40.  Aged  6  years.  Previous  health  not  stated.  Recovered.  On  the 
eleventh  day  voided  the  cojcum  and  a  part  of  the  colon,  (Chas.  King,  Lond.  Lane, 
1854.) 

No.  41.  Aged  4  months.  Previous  health  good.  Died  the  third  day.  The 
copcum  had  descended  through  the  colon,  nearly  to  the  rectum.  (Dr.  Penquier, 
L'Uuion  Medicale,  Aug.  22,  1861.) 

No.  42.  Aged  5  years.  Was  ill  witli  fever  and  pain  in  region  of  bladder  for  four 
months;  dateof  commencement  of  intussusception  not  known.  Recovered,  Passed 
by  stool  eight  inches  of  the  ileum,  the  crecum,  and  four  inches  of  the  colon,  (Dr, 
Quain,  Lond.  Path.  Soc,  Aug.  10,  1859.) 

No.  43  Age  not  stated.  Previous  liealth  good.  Died  the  third  day.  The  upper 
part  of  the  descending  colon  had  descended  into  the  inferior  part  to  the  extent  of 
two  inches.     (Dr.  Montgomery,  Lond.  Med.  Times,  December  23, 1848.) 

No.  44.  Aged  0  months.  Slight  diarrhoea  two  or  three  days  previously  to  sick- 
ness. Intussusception  in  the  transverse  colon  to  the  extent  of  two  or  three  inches. 
(E.  Y.  Steele,  Lond.  Lane,  June  23,  1849.) 

No.  45.  Aged  4  montlis.  Had  nausea  with  vomiting  for  three  weeks  previously 
to  severe  symptoms.  Died  after  six  days.  The  loAver  portion  of  the  colon,  and 
the  upper  part  of  the  rectum,  had  descended  into  the  portion  below.  (Mr.  Howship, 
Edin.  Med.  Journ.,  April,  1812.) 


APPENDIX.  731 


UNCERTAIN. 

No.  40.  A^od  4  months.  Had  disordered  bowels  from  birth.  Died  on  the  sixth 
dav.  An  intussusception  was  found  in  the  left  iUac  region.  (II.  F.  Carter,  Lond. 
Lane,  June  3,  1849.) 

No.  47.  Aged  0  years.  Previous  health  not  stated.  Recovered.  Twcnty-tliree 
inches  of  intestine  were  discharged.  (Levi  Gaylord,  Amer.  Journ.  of  Med.  Sci., 
(.)ctol)er,  1837.) 

No.  48.  Aged  13  years.  Previous  liealth  not  stated.  Recovered.  Fifteen  or 
eighteen  inches  of  ileum  were  passed  by  stool.  (F.  Bush,  Lond.  Med.  and  Phys. 
Journ.,  December  18,  1833.) 

No.  49.  Aged  13  years.  Had  occasional  purging  and  pain  in  the  bowels. 
Recovered.  A  portion  of  ileum  twelve  inches  long  was  passed.  (John  Lang, 
Lond.  Lane,  October,  1855.) 

No.  50.  Fatal.  An  invagination  of  the  intestine  was  found  in  the  rectum.  (Dr. 
Jacobi,  N.  Y.  Path.  Soc,  August  8,  1801.) 

No.  51.  Aged  9  years.  Had  dysentery  previously.  Recovered.  A  portion  of 
intestine  measuring  ten  inches  was  passed.  (Dr.  Patterson,  Medico-Chirurg.  Soc, 
Edin.) 

No.  53.  Aged  8  months.  Previous  health  good.  Died  the  second  day.  A 
portion  of  intestine  protruded.     (E.  Y.  Steele,  Lond.  Lane,  June  23,  1849.) 


INDEX. 


A  BDOMINAL  viscera,  tubercles  in,  123 

J\     Abscess,  peri-pliaryugeal,  559 

Abscess  in  lungs,  48P 

Acarus  scabiei,  711 

Accidents,  incidental  to  birth,  G3 

Acephalus,  298 

anatomical  characters,  298 
sj'mptoms,  299 
prognosis,  299 

Acid,  hydrocyanic,  in  pertussis,  257 

Acue,  syphilitic,  153 

Attusions,  cold,  in  scarlet  fever,  189 

AUin,  Dr.,  statistics  of  peri-pharyngeal 
abscess,  559 

Animal  heat,  85 

Apncea  of  the  new-born,  63 
causes,  62 
treatment,  63 

Appendix  A.,  dietetic  formula?,  715 

Ap])endix  B.,  Wm.  Budd  on  prevention 
of  scarlet  fever,  720 

Appendix  C,  Prof  Rindfleisch,  remarks 
on  the  diphtheritic  membrane,  725 

Appendix  E.,  statistics  of  state  of  liver 
in  entero-colitis,  720 

Appendix   F.,  statistics  of  intussuscep- 
tion, 728 

Aqueous  cancer  of  infants,  544 

Armor,  Dr.,  case  of  ta?uia,  637 

Arteritis,  umbilical,  69 

Artiticial  feeding,  57 

Ascaris  vermicularis,  636 
lumbricoides,  634 

Asphyxia  of  the  new-born,  62 

Atrophy  of  brain,  301 

Attitude  in  disease,  79 


BARKER,  Prof   Fordyce,  on  turpeth 
mineral  in  croup,  467 
Baths,  60 

Billard,  case  of  tetanus  infantum,  383 
cases  of  gangrene  of  mouth,  540 
Bouchut's  views  of  scrofula,  116 

on  santonin  as  an  anthelmintic,  643 
Bowditch,    Dr.,    mode    of    performing 
thoracentesis,  522 


Brain,  its  chemical  analysis,  297 

its  growth,  297 

absence  of,  298 

imperfect,  299 

atrophy,  301 

hypertrophy^  304 

congestion,  314 
Bretonneau,  on  diphtheria,  238 
Brodie,  Sir  Benjamin,  on  cliorea,  424 
Bromides  in  pertussis,  254 
Bronchitis  in  measles,  163 
Bronchial  phthisis,  132 

physical  signs,  140 
Bronchitis,  476 


causes,  477 


anatomical  characters,  477 
capillary,  478 
Complications,  480 
pneumonia,  480 
abscesses,  480 
dilation  of  bronchial  tubes,  481 
symptoms,  481 

in  capillary  bronchitis,  483 
chronic,  484 
diagnosis,  485 
prognosis,  485 
treatment,  486 
Brown-Sequard,  on  compression  of  sym- 
pathetic nerve  for  eclampsia,  379 
Bruit  de  soufflet  of  anterior  fontanelle, 

101 
Biichler,  Dr.,  cases  of  intussusception, 

670 
Bulbous  fingers,  78 
Bum  stead  on  syphilis,  151 


CALOMEL,  its  use  in  croup,  467 
Cancrum  oris,  538 
Caput  succedaneum,  64 
Care  of  mother  in  pregnancy,  20 
Carswell,  Dr.,  on  softening  of  stomach, 

582 
Castor-oil  plant  as  a  galactogogue,  47 
Catamenia,  its  effect  on  the  milk,  40 
Cavities  in  lungs,  131 
Cellulitis,  scrofulous,  111 


rr-j,  f 


INDEX. 


Cephalfpmatoraa,  64 
Cerebro-spinal  system,  diseases,  295 
Clienopodium,  G-l-i 
Chickciipox,  224 
Chiklhood,  19 
Cholera  infautum,  624 
causes,  02o 
symptoms,  625 
anatomical  characters,  027 
diagnosis,  630 
prognosis,  630 
treatment,  630 
Chorea  major,  421 
Chorea  (.chorea  minor),  415 
age,  416 
causes,  416 
sex,  417 

uterine  irrritation,  417 
anfemia,  417 
rheumatism,  418 
embolism,  420 
fright,  420 
irritation,  421 
intestinal  irritation,  421 
lesions  of  brain  and  spinal  cord, 
422 
anatomical  characters,  423 
symptoms,  424 
prognosis,  426 
cause,  426 
treatment,  427 

regimenal,  427 
medicinal,  428 
Church,  Dr.  A.  S.,  case  of  tonic  con- 
vulsions from  dentition,  550 
Cimicifuga  in  treatment  of  chorea,  429 
Circulatory  system,  82 
Cirrhosis,  syphilitic,  154 
Clark,  Prof.  A.,  case  of  syphilis  from 

vaccination,  219 
Clarke,    Dr.    Joseph,    on    treatment    of 

tetanus  infantum,  387 
Clothing,  60 
Coates,   Dr.,  treatment  of  gangrene  of 

mouth,  545 
Colitis  in  childhood,  620 
causes,  620 
symptoms,  621 
diagnosis,  623 
prognosis,  622 
treatment,  622 
CoUes,  Dr.,  on  tetanus  infantum,  388 
Colostrum,  34 

Condie,  Dr.  D.  F.,  on  erysipelas,  289 
on  turpentine  as  an  anthelmintic,  645 
erysipelas,  289 
Congestion  of  brain,  314 
causes,  314 
symptoms,  317 
anatomical  characters,  317 
prognosis,  317 
treatment,  318 
Congestion  of  stomach,  574 
Conjunctivitis  of  the  new-born,  65 
causes,  66 


Conjunctivitis — 

symptoms,  66 

treatment,  67 
Convulsions,  369 

mtcrnal,  405 
Coryza,  acute  and  chronic,  445 

anatomical  characters,  440 
symptoms,  446 
prognosis,  447 
treatment,  447 

syphilitic,  152 
Cranial  sinuses,  thrombosis  of,  308 
Craniotabes,  96 
Croup,  talse  or  spasmodic,  452 

true,  or  pseudo-membranous,  458 
Cruveilhier,  M.,  on  gelatinous  softening, 

581 
Cummings,   Dr.  W.  H.,  on   amount  of 

milk  secreted,  41 
Curvatures  in  rachitis,  97 
Cyanosis,  674 

literature  of,  675 

sex,'  678 

causes  of  malformations,  678 

time  of  commencement,  680 

symptoms,  681 

prognosis,  686 

mode  of  death,  687 

modes  of  compensation,  689 

morbid  anatomy,  689 

theories  relating  to  its  etiology  691 

treatment,  693 

D ALTON,    Prof.,   effect    of  maternal 
emotions,  23 
on  iodide  of  starch,  119 
Dartrous  diathesis,  707 
Dentition,  546 

physiological,  547 
pathological  results  of,  548 
geugivitis,  548 
stomatitis,  548 
diarrhoea,  549 
convulsions,  549 
tonic,  550 

case,  550 
paral3'sis,  550 
diagnosis,  551 
treatment,  551 
second,  554 
in  rachitis,  99 
Diagnosis  of  infantile  diseases,  000 
Diarrho-a,  585 

choleriform  624 
non-intlammatory,  585 
causes,  586 
symptoms,  587 
anatomical  characters,  588 
diagnosis,  589 
prognosis,  589 
treatment,  590 
Diday,  on  syphilis,  157 
Diet,  improper,  a  cause  of  infantile  mor- 
tahty,  27 


1 N  JJ  E  X . 


735 


Digest idii,  post-mortoni,  580 
Diii'cslivc  yysU'in,  8G 
Diplillii'dii,  238 

Ibniis.  22S 

anatoiuiciU  characters,  228 

appearance ofiiseudo-nieiiibrane,  229 

coiil'ervoid  growtli  on  it,  2^50 

adenitis,  cervical,  in,  232 

symptoms,  2;!2 

alliuminiiiia  in,  235 

nature,  2;«7 

contagiousness,  238 

incubative  period,  239 

secpiela^  239 

pai'alysis,  240 

prognosis,  241 

diagnosis,  242 

treatment,  243 
Diseases  of  umbilicus,  69 
Donne,   Dr.,  on  ascertaining  the  capa- 
bilit}^  for  wet-nursing,  29 

discovery  of  pus  in  the  milk  by  the 
microscope,  33 
Dysentery,  in  childhood,  020 
Dyspepsia,  507 


ECLAMPSIA,  369 
causes,  370 

premonitory  stage,  371 

sj'mptoms,  372 

anatomical  characters,  375 

diagnosis,  376 

prognosis,  377 

treatment,  378 
Ecthyma,  153 
Eczema,  704 

varieties,  704 

diagnosis,  706 

treatment,  707 
general,  708 
local,  709 
Electricity  as  a  galactogogue,  45 
Elliott,  Prof.  Geo.  T.,  cases  of  peri-pha- 
ryugeal  abscess,  560,  565 

use  of  raw  meat,  719 
Emotions,  effect  in  pregnancy,  20 
Emphysema  in  tuberculosis,  131 
Enteritis  in  cliildhood,  620 

causes,  630 

symptoms,  621 

diagnosis,  622 

prognosis,  622 

treatment,  622 
Entero-colitis  593 
Erysipelas  from  vaccination,  218 
Erysipelas,  284 

cases,  285 

age,  286 

point  of  commencement,  286 

causes,  286 

from  vaccination,  287 

during  epidemics  of  puerperal  fever, 
288 

symptoms,  premonitory,  289 


Erysipelas — 

syni])1oms,  290 

prognosis,  391 

duration,  291 

modes  of  death,  292 

pathological  anatomy,  292 

treatment,  293 
Erythema,  695 

forms  and  causes,  695 

prognosis,  697 

diagnosis,  697 

treatment,  697 
Ether,  in  spasmodic  laryngitis,  456 
Evanson  and  Maunsell,  on  treatment  of 
gangrene  of  mouth,  545 


T^ACIAL  paralysis,  440 

1      Falkland's,    Prof.,    preparation    of 

milk  for  infants,  715 
Features  in  disease,  76 
Feeding,  a  cause  of  infantile  mortality, 
26 
artificial,  57 
Fever  and  ague,  263 

Fleming,  Mr.,  on  retro-pharyngeal  ab- 
scess, 560 
Flint,  Prof.  Austin,  Jr.,  on  the  diet  of 

children,  27 
Flint,  Prof.  Austin,  Sen.,  prevention  of 
pitting  in  smallpox,  211 
on  thoracentesis,  531 
Foetus,  elfect  on  it  of  maternal  emotions, 

21 
Fox,  Tilbury,  on  seat  of  strophulus,  703 
Friedleben,  Dr.,  on  state  of  thyroid  gland 

in  internal  convulsions,  406 
Fungus  of  umbilicus,  71 


GALACTOGOGUES,  45 
electricity,  45 
ricinus  communis,  47 
Galactorrhoia,  causes,  48 

treatment,  49 
Gangrene  in  scarlatina,  177 
of  the  mouth,  538 

anatomical  characters,  538 
age,  539 
causes,  540 
sjnnptoms,  540 
diagnosis,  543 
prognosis,  543 
treatment,  544 
Gastric  tuberculosis,  133 
Gastritis,  574 

causes,  575 
age,  576 

case,  576 
symptoms,  577 
anatomical  characters,  577 
diagnosis,  578 
prognosis,  578 
treatment,  578 
diphtheritic,  579 


736 


INDEX. 


Gastritis — 

follicular,  579 
Gastro-intestinal  liemorrliage,  646 
Gelatinous  softoning,  580 
Giltillau,  Dr.,  on  use  of  ricinus  communis 

as  a  galactogogue,  48 
Glottis,  spasm  of,  405 
Granulations,  umbilical,  71 
Grease  in  the  horse,   its   identity  with 

vaccinia,  214 
Guersant,  M.,  on  prognosis  in  meningitis, 
359 
on  thoracentesis,  522 
extent  of  pseudo-membrane  in  croup, 
461 


HALL,  Marshall,  on  treatment  of  in- 
ternal convulsions,  414 
on  spurious  In'drocephalus,  365 
Hall,  Prof.,  case  of  unusual  lactation,  45 
Hammond,  Prof.,  on  maternal  emotions, 

22 
Harris,  Dr.  Elisha,  prevention  of  scarlet 

fever,  200 
Hassel,  Dr.,  on  Liebig's  soup,  717 
Ha-svley's  pepsin,  573 
Heart,  diseases  of,  674 
Heimacy.  tetanus  in,  386 
Helmerich's  ointment,  713 
Hemorrhage,  intra-crunial,  319 
causes,  319 

anatomical  characters,  320 
meninareal,  321 
cerebral,  323 
svmptoms,  324 
capillary,  327 
diagnosis,  328 
prognosis,  329 
treatment^  329 
umbilical,  72 
causes,  73 
sex,  age,  73 

jaundice  in  cases  of,  74 
symptoms,  75 
prognosis,  75 
treatment,  75 
gastro-intestinal,  646 
first  variety,  647 
second  varietv.  648 
third  variety,'649 

case,  648 
prognosis,  650 
treatment,  650 
Hewitt,  Dr.  Graily,  case  of  post-mortem 
digestion,  567  j 

Hillier,  on  choreic  heart  murmurs,  415     j 

causes  of  urticaria,  701 
Hogarth's  essence  of  meat,  720 
Holmes,  on  scrofulous  atfections,  113 
Hooping-cough,  247 
Hutchinson,  on  syphilis,  155 
Hydrocephalus,  congenital,  330 

anatomical  characters,  331 
case,  334 


Hydrocephalus,  congenital — 

symptoms,  334 

diagnosis,  336 

prognosis,  337 

treatment,  337 
acquired,  338 

causes,  338 

anatomical  characters,  335 

symptoms,  340 

prognosis,  340 

treatment,  341 
spurious,  363 

anatomical  characters,  363 
case,  364 

symptoms,  365 
case,  366,  367 

diagnosis,  368 

prognosis,  368 

treatment,  369 
Hypertrophy  of  brain,  303 
anatomj',  303 
causes,  304 
symptoms,  305 

case,  306 
diagnosis,  307 
prognosis,  307 
treatment,  307 


ICTERUS  of  the  new-born,  76 
i     Impetigo,  syphilitic,  153 
Imperfect  brain,  299 

case,  300 

symptoms,  300 

prognosis,  301 
Indigestion,  567 

causes,  568 

sj'uiptoms,  569 

prognosis,  571 

treatment,  571 
Infancy,  17 

its  anatomical  characters,  17 

causes  of  great  mortality  in,  18 
Inflammation  of  stomach,  574 

of  umbilicus,  70 
Intermittent  fever,  263 

.  in  fo'tus,  263 

symptoms,  264 

three  stages  of  paroxysms,  264 

congestive  or  pernicious,  265 

treatment,  266 
Internal  convulsions,  405 

causes,  406 

anatomical  characters,  408 

symptoms,  409 
case,  410 

diagnosis,  411 

prognosis,  411 

treatment,  412 
Intestines,  inflammation  of,  592 

invagination  of,  652 
Intestinal  inflammation,  592 
causes.  594 
age,  598 
symptoms,  599 


INDEX. 


737 


Intestinal  inflammation — 

anatomical  characters,  G03 
diagnosis,  GO'J 
prognosis,  009 
Ireatniont,  GIO 

regimenal,  GIO 
nu'dicinal,  GKJ 
oiicmata,  GIG 
external  treatment,  G19 
Intestinal  worms,  633 

nscaris  lumbricoides,  634 
vermieularis,  636 
triclu)ce])iialus  dispar,  636 
ta;nia,  God 

canses,  637 
symptoms,  639 
diagnosis,  416 
prognosis,  G43 
treatment,  643 
Intussusception,  653 

Avithout  sj-mptoms,  653 
with  sj-mptoms,  653 
previous  liealth,  653 
causes,  G54 
age,  655 

seat  and  pathological  anatomy, 
656 
of  small  intestines,  656 

cases,  057 
in  large  intestines,  659 
symptoms,  653 
diagnosis,  6G5 
duration,  665 
prognosis,  066 
mode  of  death,  668 
treatment,  668 
Iodine  in  scrofula,  119 


JACKSON,  Dr.  James,  on  treatment 
of  bronchitis,  486 
on  second  dentition,  554 
treatment  of  cholera  infantum,  631 
Jacobi,  Prof  A.,  on  laryngismus,  407 

statistics  of  croup,  473 
Jaundice  in  the  new-born,  76 
Jenkins,   Dr.   J.   Foster,   on    umbilical 

hemorrhage,  73 
Jenner,  Edward,  introduction  of  vacci- 
nation, 313 
Jenner,    Sir  Wm.,    heart   murmurs    in 

chorea,  415 
Jesty,  Benjamin,  the  first  vaccinator,  313 


TT'ERMES  mineral,  a  cause  of  gastritis, 
JV     575 

Kilda,  St.,  tetanus  in,  386 
Krackowizer,  Dr.,  cases  of  tracheotomy 
in  croup,  473 


LACTATION,  38 
course  of,  54 
hindrances  to,  39 

47 


Lactation — 

facts  and  rules  in  reference  to,  33 
Lanugo,  17 
Laryngitis,  simple,  acute,  449 

symptoms,  449 

chronic,  450 

anatomical  characters,  451 

treatment,  451 
spasmodic,  453 

causes,  453 

symptoms,  453 

anatomical  characters,  454 

pathology,  454 

diagnosis,  454 

prognosis,  455 

treatment,  455 
pseudo-membranous,  458" 

causes,  459 

anatomical  characters,  459 

symptoms,  463 

pathological  characters,  464 

diagnosis,  4G5 

prognosis,  465 

treatment,  466 

tracheotomy,  473 
Leaming,  Dr.  J.  11.,  case  of  erysipelas, 

388 
Lewis,  Dr.  Caspar,  use  of  raw  meat,  718 
Liebig's  beef-tea,  719 

soup,  716 
Liver,  its  state  in  entero-colitis,  607 
Livingston,  Dr.,  case  of  peri-pharj^ngeal 

abscess,  565 
Lungs,  tubercles  in,  139 


MALFORMATIONS,  a  cause  of  death, 

Maternal  emotions,   effect  of,   in   preg- 
nancy, 30 
Measles,  159 

symptoms,  159 

anomalies,  163 

complications,  163 

anatomical  characters,  166 

nature,  1G6 

diagnosis,  106 

prognosis,  167 

treatment,  1G7 
Meigs,  Dr.  J.  F.,  on  chenopodium  as  an; 
anthelmintic,  644 

and    Pepper,     Drs.,    treatment    of 
chronic  coryza,  448 
Meningitis,  simple  and  tubercular,  343 

age,  344 

anatomical  characters,  344 

causes  349 

premonitory  stage,  349 

symptoms,  350 
case,  355 

diagnosis,  356 

prognosis,  357 

treatment,  359 
Microcephalus,  301 
Milk,  human,  36 


738 


INDEX. 


Milk- 
modifications,  from  diet,  36 

from  retention  in  breast,  38 
by  age  and  nervous  impressions, 

'34 
by  catamenia  and  pregnancy,  40 

quantity,  required,  41 

scantiness,  43 

examination  of,  51 

excess  of  salines  in,  53 

vibriones  in,  53 

its  composition,  58 

of  animals,  58 
Minchin's  mode  of  examining  milk,  51 
Minot,  Dr.  Francis,  on  umbilical  hemor- 
rhage, 73 
Morbilli,  159 
Mortality  of  early  life,  23 

causes,  24-28 
Mother,  care  of,  in  pregnancy,  20 

effect  of  maternal  impressions,  21 
Mouth,  inflammation  of  cavity  of,  524 
Movements  in  disease,  79 
Mucuna  ])ruriens  as  an  anthelmintic,  645 
Muguet,  533 
Mumps,  261 


NECROSIS,  infantilis,  538 
Nephritis  in  scarlatina,  180 
Nervous  svstem,  88 
Nestle' s  food,  59 
Noma,  538 

Noyes,  Prof.  H.  D.,  on  use  of  ophthal- 
moscope, 296 


ffiSOPIIAGITIS,  566 
anatomical  characters,  566 
treatment,  567 
Oidium  all)icans  in  sprue,  534 
Ophthalmia  neonatorum,  65 
two  forms,  67 
symptoms,  66 
treatment,  67 
Ophthalmoscope  in  diseases  of  brain,  396 
Ostco-malacia,  92 
Otitis,  scrofulous,  113 
Otorrhoea,  183 


PAIN  as  a  svmptom,  88 
Papnhp,  703 
Paralysis,  diphtheritic,  240 
facial,  440 

causes,  440 
symptoms,  440 
prognosis,  440 
treatment,  441 
Paralysis,  infantile,  431 
causes,  431 
symptoms,  433 
prognosis,  433 
progress,  433 
etiology,  434 


Paralysis,  infantile — 

anatomical  characters,  435 
diagnosis,  437 
prognosis,  437 
treatment,  438 
Paralysis  with  apparent  hypertrophy,  441 
symptoms,  442 
anatomical  characters,  443 
causes,  444 
prognosis,  444 
treatment,  444 
Parker,  Dr.  E.  H.,  treatment  of  entero- 
colitis, 613 
lesions  of  cholera  infantum,  639 
Parker,    Prof    Willard,    case    of  peri- 
pharyngeal abscess,  564 
Parotiditis,  361 
symptoms,  361 
nature,  203 
diagnosis,  363 
treatment,  263 
Peacock,  on  growth  of  brain,  397 
Pemphigus,  syphilitic,  153 
Pepsin  in  indigestion,  573 
Peritoneal  tuberculosis,  133 
Peritonitis,  tubercular,  133 
Peri-pharyngcal  abscess,  559 


age,  559 


causes,  559 

anatomical  characters,  561 

symptoms,  561 
case,  562 

duration,  563 

diagnosis,  564 

prognosis,  565 

treatment,  565 
Pertussis,  247 

symptoms,  247 

three  stages,  248 

complications,  350 

convulsions.  350 

bronchitis,  351 

pneumonitis,  251 

emphj'sema,  253 

diagnosis,  253 

prognosis,  254 

treatment,  255 

belladonna,  256 
hydrocyanic  acid,  257 
bromides,  258 
emetics,  259 
Pharyngitis,  simple,  555 

anatomical  characters,  555 

causes,  556  , 

symptoms,  556 

prognosis  557 

diagnosis,  557 

treatment,  557 
Phthisis,  122 
Phlebitis,  umbilical,  69 
Pleuritis,  507 

causes,  508 

cases,  510,  517 

anatomical  characters,  511 

symptoms,  513 


INDEX. 


739 


Plcuritis — 

physical  sip;ns,  514 
diagnosis,  ol7 
l^roii'iiosis,  ."its 
trciUnicnt,  51!) 
thoracentesis,  531 
Pneumonitis,  41)0 

causes,  491 

anatomical  cliaracters,  493 
croupous,  4!)4 
catarriial,  495 
cheesy,  407 
symptoms,  499 
physical  si_i;-ns,  501 
diagnosis,  502 
prognosis,  504 
treatment,  504 
in  measles,  164 
Post-mortem  digestion,  580 
Pock,  vaccine,  its  anatomy,  217 
Post,  Prof.  A.,  case  of  peri-pharyngeal 

abscess,  564 
Pregnancy,  its  efiTect  on  the  milk,  40 
Protection  from  vaccination,  321 
Pulmonary  cavities,  131 

tuberculosis,  139 
Pulse  in  health,  83 
in  disease,  84 


RACHITIS,  91 
causes,  93 

age,  91 

anatomical  characters,  94 

craniotabes,  96 

curvatures,  97 

symptoms,  100 

complications,  103 

diagnosis,  103 

prognosis,  103 

treatment,  104 
Radclifle,  Mr.,  on  treatment  of  chorea, 

430 
Remittent  fever,  267 

symptoms,  268 

diagnosis,  268 

treatment,  268 
Respiration  in  health,  80 

in  disease,  81 
Respiratory  sj'stem  in  children,  80 

diseases  of,  445 
Retro-pharyngeal  abscess,  559 
Revaccination,  321 
Reynolds,  Dr.  J.  B.,  case  of  diphtheria, 

240 
Rheumatism,  acute,  377 

its  frequency  in  children,  377 

causes,  278 

symptoms,  378 

complications,  380 

duration,  280 

prognosis,  380 

diagnosis,  381 

treatment,  383 
Ricinus  communis,  as  a  galactogogue,  47 


Rickets,  91 

Rokitansky  on  hypertrophy  of  brain,  304 

Roseola,  698 

symi)toms,  699 

causes,  700 

prognosis,  700 

diagnosis,  700 

treatment,  700 
Routh,  Dr.,  mortality  from   change  of 
tcm]ierature,  2{> 

plethora,  a  cause  of  insufficient  milk, 
44 
Rubeola,  159 


OCABIES,  711 

U     acarus  scabiei,  711 

symptoms,  713 

diagnosis,  712 

treatment,  713 
Scantinesss  of  milk,  43 
Scarlatina,  169 

symptoms,  169 

irregular  form,  173 

malignant  form,  174 

complications,  175 

sequela3,  178 

nephritis,  183 

otorrha?a,  183 

anatomical  characters,  183 

nature,  183 

incubative  period,  185 

diagnosis,  187 

prognosis,  188 

treatment,  189 

prophylaxis,  198 
Scrofula,  104 

causes,  105 

vaccination  as  a  cause,  106 

commuuicabllity,  106 

anatomical  cliaracters,  109 

symptoms,  110  •  ^ 

coryza,  113 

otitis,  113 

cellulitis.  111 

its  relation  to  tuberculosis,  114 

prognosis,  117 

treatment,  118 
Scrofulous  affections,  113 
Seguin,  Dr.,  effect  of  maternal  emotions 

on  foetus,  33 
Skene,  Prof.,  case  of  taenia,  637 
Skin  diseases,  695 
Smallpox,  301 

Smith,  Prof  Stephen,  on  umbilical  hem- 
orrhage, 73 

operation  for  congenital  hydrocepha- 
lus, 336 
Softening,  gastro-intestinal,  580 
Spasm  of  glottis,  405 
Spigelia  marilandica,  as  an  anthelmintic, 

643 
Sprue,  535 

Steam,  its  employment  in  croup,  469 
Stille,  Dr.  Moreton,  on  cyanosis,  677 


740 


INDEX. 


Stomach,  congestion  of,  574 
inflammation  of,  5G6 
tubercles  in,  18;> 
Stomatitis,  simple,  534 
causes,  524 
symptoms,  526 
appearances,  526 
treatment,  527 
ulcerous,  537 
causes,  528 
symptoms,  557 
prognosis,  529 
treatment,  529 
follicular,  530 
causes,  531 
symptoms,  531 
diagnosis,  533 
prognosis,  533 
treatment,  232 
Strabismus,  78 
Strophulus,  703 
varieties,  703 
causes,  703 
treatment,  703 
St.  Guy's  dance,  415 
St.  Vitus'  dance,  415 
Strychnine  in  treatment  of  chorea,  428 
Swett,  Prof,  case  of  hemorrhage,  649 
Swinepox,  224 
Syphilis,  149 
etiology,  149 
clinical  history,  150 
coryza,  152 
mucous  patches,  152 
roseola,  153 
pemphigus,  153 
acne,  153 
impetigo,  158 
ecthyma,  153 
visceral  lesions,  154 
prognosis,  156 
treatment,  156 


T^NIA,  636 
1      Teething,  546 
Temperature,  85 
Tetanus  infantum,  383 
cases,  383 

period  of  commencement,  385 
frequency,  385 
causes,  387 

unclcanliness,  388 
irritation  in  bowels,  388 
changes  of  temperature,  389 
inflammation  of  umbilical  ves- 
sels, 390 
meningitis,  393 
injury  of  brain,  395 
anatomical  characters,  396 
symptoms,  398 
mode  of  death,  400 
prognosis,  400 
duration  of  fiital  cases,  401 
of  favorable  cases,  402 


Tetanus  infantum — 
diagnosis,  403 
preventive  treatment,  403 
treatment,  403 
Thorax,  shape,  in  tuberculosis,  143 
Thrombosis  in  cranial  sinuses,  308 
causes,  311 

anatomical  characters,  309 
symptoms,  313 
diagnosis,  313 
prognosis,  313 
treatment,  313 
Thrush,  533 

anatomical  characters,  533 
symptoms,  535 
causes,  535 
diagnosis,  536 
prognosis,  536 
treatment,  536 
Thymic  asthma,  405 
Trismus,  383 

Trousseau,  on  syphilitic  tint,  151 
Tuberculosis,  133 

its  relation  to  scrofula,  115 
etiology,  133 

anatomical  characters,  126 
symptoms,  135 
anasarca,  136 
emaciation,  136 
fever,  136 

in  bronchial  phthisis,  139 
in  pulmonary  phthisis,  140 
in  tubercles  of  pleura,  143 
in  gastric  and  intestinal  tu 
bercles,  144 
diagnosis,  144 
prognosis,  147 
treatment,  148 
Tubercles  in  lungs,  128 
stomach,  133 
intestines,  133 
bronchial  gland^lSl 
Typhoid  fever,  269  ^ 
causes,  269 

anatomical  characters,  270 
symptoms,  271 
complications,  273 
diagnosis,  274 
duration,  275 
prognosis,  275 
treatment,  276 


TTLCERATION  of  umbilicus,  70 
U     Umbilicus,  diseases,  69 
inflammation  of  vessels,  69 

of  umbilicus,  70 
ulceration  of,  70 
treatment,  71 
granulations,  71 
fungus,  71 
hemorrhage,  72 
inflammation  of,  284 
Urticaria,  701 
causes,  701 


IN])EX. 


741 


Urticaria — 

pro^'iiosis,  701 
diiii^'iiosis,  701 
treatment,  703 


yACCINATIONS,  subsequent,  230 
»      sinirious,  231 
Vaccinia,  212 

history  of,  213 

appearance,  21G 

symptoms,  21G 

anomalies,  217 

complications,  217 

sccpu'ls,  217 

subsecpient  vaccinations,  220 

protection  from,  31G,  221 

revaccination,  231 

selection  of  virus,  223 
Varicella,  334 

symptoms  of,  224 

diagnosis,  235 

prognosis  and  treatment,  236 
Variola,"  301 

incubative  period,  201 

stage  of  invasion,  201 
of  eruption,  203 
of  desiccation,  204 
Varioloid,  205 

mode  of  death,  206 

anatomical  characters,  307 

complications,  308 


Varioloid — 

prognosis,  308 

diagnosis,  200 

treatment,  209 
Vibriones  in  milk,  52 
Villemin  on  origin  of  tulierclcs,  124 
Virus,  vaccine,  its  selection,  223 
Voice  in  disease,  79 

Voss,  Dr. ,  cases  of  tracheotomy  in  croup, 
473 


WARE,  Dr.,  statistics  of  croup,  461 
Waxy  degeneration  in  rachitis,  99 
Weaning,  54 

age  for,  55 

mode,  56 
West,  Dr.  Chas.,  case  of  thrombosis,  310 

treatment  of  chorea,  439 

on  gelatinous  softening,  581 
Wet-nurse,  selection  of,  49 

syphilis  in,  50 
Whitehead,  Dr.,  effect  of  maternal  emo- 
tions on  the  foetus,  33 
White  softening,  gastro-intestinal,  580 
White,  Prof.  J.  P.,  case  of  cyanosis,  694 
Whytt,  Dr.,  on  meningitis,  3*41 
Worms  intestinal,  633 


'INC,  oxide  of,  in  eczema,  710 


THE   END. 


THOMAS  ON  DISEASES  OF  WOMEN.— Now  Ready. 


A  PRACTICAL  TREATISE 

ON  THE  DISEASES  OF  WOMEN. 

By  T.  GAir.LARD  THOMAS,  M.D., 

Professor  of  Obstetrics  and  Dispasps  of  Woiiieu  ami  Cliildren  in  the  Collego  of  Physicians  and 
Surgeons    New  York;  ()l)stetric  Physiciau  to  tlie  Strangers'  and  llie  Uoosevelt  Hos- 
pitals; Consulting  Pliysician  to  the  N.  Y.  State  Women's  Hospital,  &c. 

With  about  Two  Hundred  and  Fifty  Illustrations. 

THIKD   EDITION,   ENLAEGED   AND   THOROUGHLY   REVISED. 

In  one  large  and  handsome  octavo  volume  of  784  pages  :  leather,  $6  00  ;  cloth,  $5  00. 

The  exhaustion  of  two  very  large  editions  in  a  little  more  than  three  years  shows  that  the 
author  hiis  not  failed  in  his  endeavor  to  supply  the  admitted  want  of  a  work  which  should,  in  a 
moderate  compass,  furnish  a  complete  view  of  all  the  modern  aspects  of  gyna;cology.  Stimulated 
by  the  very  favorable  reception  accorded  to  his  labors,  he  has  sought  to  render  the  present  edition 
still  more  worthy  than  its  predecessors.  Every  portion  of  the  work  has  been  thoroughly  revised, 
several  new  chapters  and  a  number  of  new  illustrations  have  been  introduced,  and  the  most 
painstaking  care  has  been  bestowed  to  make  it  a  full  and  trustworthy  guide  for  the  student  and 
practitioner.  To  accommodate  the  numerous  additions  the  size  of  the  page  has  been  enlarged, 
notwithstanding  which  the  number  of  pages  has  been  increased  by  nearly  one  hundred  and  fifty; 
in  fact,  the  present  edition  contains  nearly  one -third  more  matter  than  the  preceding,  notwith- 
standing which  it  has  been  kept  at  the  former  very  moderate  price.  The  work,  it  is  therefore 
hoped,  will  continue  to  maintain  its  position  as  the  favorite  book  for  consultation  by  all  who 
have  to  treat  this  frequent  and  important  class  of  diseases. 


From  Prof.  Fordvce  Barker,  Bdlevue  Hospital 
Miidical  College,  New  York. 

A  work  which  I  estimate  very  highly  and  which  I 
have  always  taken  every  opportunity  to  commend 
to  students  and  the  profession.  I  have  carefully 
looked  over  this  edition,  and  comparing  it  with  the 
two  former  ones,  I  have  been  greatly  impressed  with 
the  conscientious  labor,  as  well  as  the  ability,  with 
which  Professor  Thomas  has  kept  the  work  up  to 
represent  the  advanced  and  progressing  science  of 
the  day. 

From  Prof.  De  Laskie  Miller,  Hush  Medical 
College,  Chicago. 
My  appreciation  of  the  work  is  indicated  by  the 
fact  that  I  always  mention  it  first  when  recommending 
works  on  this  department  to  students  or  others. 

From  Prof.  J.  Algernon  Temple,  Trinity  College, 
Toronto. 

I  can  only  say  that  in  my  opinion  it  is  now  the 
most  complete  work  of  its  kind.  The  well-known 
reputation  of  the  author  and  the  many  improvements 
in  this  edition  place  it  in  the  foremost  rank  of  medical 
literature.  I  shall  have  great  pleasure  in  recom- 
mending it  to  my  class. 

From  Prof.  Alex.  J.  C.  Skene,  Lo7ig  Island  College 
Hosx>ital. 

This  edition  shows  that  the  professor  is  determined 
to  keep  fully  up  to  the  times.  I  shall  have  the  plea- 
sure of  continuing  to  recommend  this  work  to  my 
class  of  students  as  the  best  on  the  subject  to  be 
found  anywhere. 

From  Prof.  J.  S.  D.  Cullen,  Iledical  College  of 
Virginia. 

A  work  which  I  prize  very  much  both  for  the  text 
and  for  the  admirable  manner  in  which  it  is  pub- 
lished. It  is  the  text-book  which  I  recommend  to 
my  class  and  to  my  professional  friends. 

From  Prof.  F.  M.  Eobrrtson,  Charleston  Medical 
College. 

I  have  no  doubt  that  I  shall  find  it  worthy  of  even 
greater  commendation  than  the  preceding  editions, 
as  I  find  that  it  has  been  greatly  enlarged  and  brought 
fully  up  with  the  times. 

From  Prof.  Fra.vk  Wells,  Cleveland  Medical 
College. 
The  book   has   been   for  some  time  used   in   our 
school,  and  on  the  perusal  of  the  new  edition  I  am 


led  to  more  strongly  than  ever  recommend  it  to  the 
students  and  to  the  practitioners  of  our  city  as  a  work 
furnishing  a  very  comprehensive  treatise  on  the 
subject. 

From  Prof.  A..  F.  A.  Kino,  National  3Iedical  College, 
Washington,  D.  O. 

On  referring  to  it  for  advice  in  regard  to  some  diffi- 
cult cases  now  under  treatment  I  have  been  delighted 
with  its  practical  character,  and  shall  take  pleasure 
in  recommending  it  as  a  text-book  to  my  class. 

From  Prof.  J.  C.  Shrader,  Iowa  State  University. 

I  shall  take  great  pleasure  in  recommending  it  to 
the  students  in  the  Medical  Department  uf  the  Iowa 
State  University,  as  the  standard  work  on  gynaeco- 
logy. 

Its  able  author  need  not  fear  comparison  between 
it  and  any  similar  work  in  the  English  language; 
nay  more,  as  a  text-book  for  students  and  as  a  guide 
for  practitioners,  we  believe  it  is  unequalled.  In  the 
libraries  of  reading  physicians  we  meet  with  it  oftener 
than  any  other  treatise  on  diseases  of  women.  We 
conclude  our  brief  review  by  repeating  the  hearty 
commendation  of  this  volume  given  when  we  com- 
menced :  if  either  student  or  practitioner  can  get  but 
one  book  on  diseases  of  women,  that  book  should  be 
"Thomas  " — Am.  Journ.  Med.  Sciences,  April,  1S72. 

Of  the  work  itself,  in  the  original  block,  we  need 
hardly  make  any  criticism  at  this  date.  It  has  firmly 
established  itself  as  the  American  text-book  of  gyne- 
cology. Without  being  prolix,  it  treats  of  the  disor- 
ders to  which  it  is  devoted,  fully,  perspicuously,  and 
satisfactorily.-  It  will  be  found  a  treasury  of  know- 
ledge to  every  physician  who  turns  its  pages. — Am. 
Journ.  of  Syphilography,  April,  1872. 

No  book  in  American  medical  literature  has  been 
so  flatteringly  received  by  the  profession  as  this,  and 
no  one  making  the  least  pretensions  to  the  study  of 
uterine  diseases  can  do  without  it.  For  clearness  of 
style  and  therapeutics,  it  has  no  parallel.— Fa.  Clin. 
Record,  April,  1872. 

It  better  represents  the  present  condition  of  gynae- 
cology than  any  work  in  the  English  language  of  which 
we  know.  W^ant  of  space  forbids  our  entering  into 
details ;  nor  is  it  necessary,  for  all  our  readers  who 
are  not  already  supplied  with  a  copy  of  one  of  the 
previous  editions  will  be  sure  to  get  this;  that  is,  if 
at  all  interested  in  the  treatment  of  diseases  of  wo- 
men.—.•I?7ie)-Jca7i  Practitioner,  April,  1872. 


HENRY   C.   LEA,   Philatlelphia. 


WORKS  ON  DISEASES  OE  CHILDEEN. 

SMITH  ON  WASTING  DISEASES  OF  CHILDEEN. 


THE  WASTING  DISEASES  OF  INFANTS  AND  CHILDREN. 

By  EUSTACE  SMITH,  M.D. 

Second  American,  from  the  Second  and  Enlarged  London  Edition. 

In  one  very  handsome  octavo  volume  of  2&G  priges  ;  extra  cloth,  §2  50.  {Just  Issued.) 
The  final  chapter  on  the  diet  and  treatment  of  chil-  '  children.  The  author,  as  physician  to  the  largest  free 
dren  in  health  and  disease  will  be  found  especially  Dispensary  for  children  in  London,  has  enjoyed  an 
useful  to  the  juuiorpractitioner,  who  is  often  at  a  loss  experience  equalled  by  few,  and  surpassed  by  none, 
in  the  management  of  children  as  regards  the  food  to  j  —Richmond  and  Louisville  Medical  Journal,  Aug. 
be  administered     It  contains  very  minute  and  elabo-  i  1S71. 

rate  directions,  and  scales  of  dieting  for  different  ages  '  Xu  a  highly  creditable  manner  the  doctor  has  ex- 
and  conditions.  We  are  glad  to  be  able  to  recommeud  piored  this  important  field,  and  has  brought  out  prac- 
this  work  as  one  of  sterling  merit,  and  one  which  we  tically  the  prominent  salient  points  on  tlie  causes, 
have  no  doubt  will  be  very  favorably  received  and  diagnosis,  prognosis,  pathology,  morbid  anatomy,  and 
considered  by  the  profession.  — 2>it&Zi«  Quarterly  the  treatment  of  the  diseases  of  childhood  of  which 
Journal,  Aug.  1S71.  !  wasting  is  a  symptom.     The  clinical  facts  thus  made 

As  the  first  edition  of  this  admirable  work  was  re-  \  applicable  give  this  work  a  special  value.  It  is  a 
viewed  carefully  in  this  journal,  it  is  unnecessary  to  bo.)k  well  worthy  of  careful  perusal,  and  we  would 
add  much  in  regard  to  it.  It  has  been  enlarged  by  the  cordially  recommend  it  to  those  who  are  interested 
addition  of  most  valuable  matter  in  connection  with  in  the  diseases  of  infancy  and  childhood.— jTft*  New 
mucous  diarrhoea,  and   the  proper  diet  for  invalid     York  Journ.  of  Psijchological  Medicine,  April,  1S72. 


"WEST  ON  CHILDREN". 


LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILDHOOD. 

By  CHARLES  WEST, 

Physician  to  the  Hospital  for  Sick  Children,  &c. 

FOFRTH  AmEHICAX,   FEOM  THE  FiFTn  AXD  REVISED  ExGLISII  EdITIOX. 

In  one  large  and  handsome  octavo  volume  of65&  pages  ;  cloth,  $4  50  ;  leather,  $5  50. 
All  our  readers  are,  doubtless,  familiar  with  Dr.  i  The  work  of  West  on  the  Diseases  of  Children  is 
West's  admirable  volume,  and  will  welcome  the  ap-  translated  into  the  chief  European  languages,  and 
pearauce  of  a  new  edition.  No  praise  is  needed  of  a  extensively  used  ;  and  the  reason  is,  we  believe,  sim- 
book  so  well  known,  which  has  placed  its  author  in  ply,  that  there  is  nothing  to  be  found  in  any  language 
the  first  rank  of  British  physicians,  and  gained  him  at  all  equal  to  it.— Edinburgh  Med.  Journal,  May, 
an  enduring  reputation  as  an  authority  on  infantile  1S69. 
disease. — Brit,  and  For.  Med.-Chir.  Rev.,  Oct.  1S70. 

By  the  same  Author— Just  Issued. 
ON  SOME  DLSORDERS  OP  THE  NERVOUS  SYSTEM  IN  CHILDHOOD. 
Being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  of  London,  in 
March,  1871.     In  one  neat  volume,  small  12mo.  ;  cloth,  $1. 

With  the  assurance  to  our  readers  that  this  little 
book  abounds  in  valuable  practical  hints  which  will 
assist  them  in  the  treatment  of  this,  confessedly  the 


most  difiionlt  class  of  disease,  we  recommend  it  to 
their  studv.— SY.  Louis  Medical  and  Surgical  Jour- 
nal, Jan.  1S72. 


CONDIE   ON  CHILDEEN. 


A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

By  D.  FRANCIS  CONDIE,  M.D. 

SIIXTII    EXDITIOnsr,     T1^0TiOTJG:B3ilL,-^r    K,EV"ISEI3- 
Li  one  large  and  handsome  octavo  volume  of  nearlij  SOO  closely  fruited  pages ;  extra  cloth,  $5  25; 

leather,  $6  25. 
A  work  which  has  passed  through  five  bona  fide  gone  a  careful  and  thorough  revision,  and  the  ad- 
editions,  and  uf  which  a  sixth  has  been  called  "for,  vances  recently  made  in  our  knowledge  of  the  various 
may  be  regarded  as  being  beyond  the  bounds  of  cri-  diseases  of  childliood  have  been  carefully  incorpo- 
ticism  ;  that  high  tribunal,  tlie  profession,  having  rated  in  the  several  chapters.  This  will  be  manifest 
already  recorded  a  verdict  in  its  favor.  All  that  is  on  a  comparison  of  the  present  with  the  previous 
needed,  in  a  notice  of  the  present  edition  of  Dr.  Con-  edition. — Am.  Journ.  Med.  Sciences,  April,  1S6S. 
die's  well-known  treatise,  is  to  state  that  it  has  under- 


GUEESANT  ON  SURGICAL  DISEASES  OF  CHILDREN. 


SURGICAL  DISEASES  OF  INFANTS  AND  CHILDREN. 

By  M.  p.  GUERSANT, 

Honorary  Surgeon  to  the  Hospital  for  Sick  Children,  Paris. 

Translated  by  RICHARD  J.  DUNGLISON,  M.D. 

This  work,  now  appearing  in  the  "Medical  News  and  Library,"  will  be  continued  to  comple- 
tion in  1872,  when  it  will  be  issued  sejjarately  in  a  handsome  octavo  volume  of  nearly  400  pages. 
It  will  be  found  to  contain  much  which,  while  of  everyday  importance  to  the  practitioner,  can 
scarcely  be  found  in  the  ordinary  text-books. 

HENRY    C.    LEA,    Philadelphia. 


(latk  lea  4.  blanchap.d's) 
OF 

MEDICAL  AND  SURGICAL  PUBLICATIONS. 


•  In  asking  the  attention  of  the  profession  to  tlie  works  contained  in  the  following^ 
pages,  the  publisher  would  state  that  no  pains  are  spared  to  secure  a  continuance  of 
the  confidence  earned  for  the  publications  of  the  house  by  their  careful  selection  and 
accuracy  and  finish  of  execution. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 
throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works 
not  kept  in  stock.  Where  access  to  bookstores  is  not  convenient,  books  will  be  sent 
by  mail  post-paid  on  receipt  of  the  price,  but  no  risks  are  assumed  either  on  the 
money  or  the  books,  and  no  publications  but  my  own  are  supplied.  Gentlemen  will 
therefore  in  most  cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

An  Illustrated  Catalogue,  of  64  octavo  pages,  handsomely  printed,  will  be  for- 
warded by  mail,  postpaid,  on  receipt  of  ten  cents. 

HENRY  C.  LEA. 

No8.  706  and  708  Sansom  St.,  Philadelphia,  April,  1873. 


ADDITIONAL  INDUCEMENT  FOR  SUBSCRIBERS  TO 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES. 


THKEE  MEDICAL  JOUENALS,  containing  over  2000  LAEGE  PAGES, 

Free  of  Postage,  for  SIX  DOLLAES  Per  Annum. 

TERMS    FOE   1873: 

The  American  Journal  of  the  Medical  Sciences,  and  "I  Five  Dollars  per  annum. 
The  Medical  News  and  Library,  both  free  of  postage,      j  inadvance. 

O  R., 

The  American  Journal  of  the  Medical  Sciences,  published  quar-^  ^^^  Dollars 

terly  (1150  pages  per  annum),  with  | 

The  Medical  News  and  Library,  monthly  (384  pp.  per  annum),  and  [-  per  anaum 
The  Half-Yearly  Abstract  of  the  Medical  Sciences,  published  j  -^  advance 
Feb.  and  August  (GOO  pages  per  annum),  all  free  of  postage.     J 

SEPARATE  SUBSCRIPTIONS  TO 

The  American  Journal  of  the  Medical  Sciences,  subject  to  postage  when  not  paid 

for  in  advance.  Five  Dollars. 
The  Medical  News  and  Library,  free  of  postage,  in  advance,  One  Dollar. 
The  Half-Yearly  Abstract,  Two  Dollars  and  a  Half  per  annum  in  advance.     Single 

numbers  One  Dollar  and  a  Half. 

It  is  manifest  that  only  a  very  wide  circulation  can  enable  so  vast  an  amount  of 
valuable  practical  matter  to  be  supplied  at  a  price  so  unprecedentedly  low.  'J'he  pub- 
lisher, therefore,  has  much  gratification  in  stating  that  the  rapid  and  steady  increase 
in  the  subscription  list  promises  to  render  the  enterprise  a  permanent  one,  and  it  is 
with  especial  pleasure  that  he  acknowledges  the  valuable  assistance  spontaneou.sly 
rendered  by  so  many  of  the  old  subscribers  to  the  "Journal,"  who  have  kindly  made 

(For  "  American  Chemist,"  see  p.  11.) 
(For  "Obstetkical  Jourjial,"  aee  p.  22  ) 


2         Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences). 

known  among  iheir  friends  the  advantages  thus  ofiFered  and  have  induced  them  to 
suliscribe.  Eelying  upon  a  continuance  of  these  friendly  exertions,  he  hopes  to  be 
alile  to  maintain  the  unexampled  rates  at  which  these  works  are  now  supplied,  and  to 
succeed  in  his  endeavor  to  place  upon  the  table  of  every  reading  practitioner  in  the 
United  States  a  monthly,  a  quarterly,  and  a  half-yearly  periodical  al  the  comparatively 
trifling  cost  of  Six  Dollars  per  annum. 

These  periodicals  are  universally  known  for  their  high  professional  standing  in  their 
several  spheres. 

I. 

THE  AMERICAN  JOmiS^AL  OF  THE  MEDICAL  SCIENCES, 
Edited  by  ISAAC  HAYS,  M.  D., 

is  published  Quarterly,  on  the  first  of  January,  April,  July,  and  October.  Each 
number  contains  nearly  three  hundred  large  octavo  pages,  appropriately  illustrated, 
wherever  necessary.  It  has  now  been  issued  regularly  for  nearly  fifty  years,  during 
almost  the  whole  of  which  time  it  has  been  under  the  control  of  the  present  editor. 
Throughout  this  long  period,  it  has  maintained  its  position  in  the  highest  rank  of 
eiedical  periodicals  both  at  home  and  abroad,  and  has  received  the  cordial  support  of 
the  entire  profession  in  this  country.  Among  its  Collaborators  will  be  found  a  large 
number  of  the  most  distinguished  names  of  the  profession  in  every  section  of  the 
United  States,  rendering  the  department  devoted  to 

ORiaiNAL     COMMIJNIOATIC^NS 

full  of  varied  and  important  matter,  of  great  interest  to  all  practitioners.  Thus,  during 
1872,  articles  have  appeai'ed  in  its  pages  from  nearly  one  hundred  gentlemen  of  the 
highest  standing  in  the  profession  throughout  the  United  States.* 

Following  this  is  the  "Review  Department,"  containing  extended  and  impartial 
reviews  of  all  important  new  works,  together  with  numerous  elaborate  "Analytical 
AND  Bibliographical  Notices"  of  nearly  all  the  medical  publications  of  the  day. 

This  is  followed  by  the  "  Quarterly  Summary  of  Improvements  and  Discoveries 
{N  THE  Medical  Sciences,"  classified  and  arranged  under  different  heads,  presenting 
a  very  complete  digest  of  all  that  is  new  and  interesting  to  the  physician,  abroad  as 
well  as  at  home. 

Thus,  during  the  year  1872,  the  "Journal"  furnished  to  its  subscribers  Eighty-fonr 
Original  Communications,  Out  Hundred  and  Twenty-nine  Reviews  and  Bibliograph- 
icarNotices,  and  Three  Hundred  and  seven  articles  in  the  Quarterly  Summaries,  mak- 
injy  a  total  of  about  Five  Hundred  articles  emanating  from  the  best  professional 
minds  in  America  and  Europe. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "  Journal"  are 
successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  a 
national  exponent  of  medical  progress  : — 

Dr.  Hays  keeps  his  great  Araerirnn  Quarterly,  in  matter  it  contains,  and  has  established  for  itself  a 
which  he  is  now  assisted  by  Dr.  Minis  Hays,  at  the  reputation  in  every  country  where  medicine  is  ciil- 
head  of  his  country's  medical  periodicals — Dublin  tivated  as  a  science. — Brit,  and  For.  Jiled.-Chirurg. 
Medical  Press  and  Circular,  March  S,  1S71.  I  Review,  April,  1S7I. 


Of  English  periodicals  the  Lnncft,  and  of  American  I      One  of  the  best  of  its  Vi^A.— London  Lancet,  Anc. 

Almost  the  only  one  that  circulates  everywhere, 
all  over  the  Uniun  and  in  Europe. — London,  Medical 


the  Am.  Journal  of  the  Medical  Hciences,  are  to  be 
regarded  as  necessities  to  the  reading  practitioner. — 
A'    r  Medical  Ga.zeite,  Jan.  7,  1S71. 

The  American  Journal  of  the  Medical  Sciences  !  Tinier,  Sept.  5,  1868. 
yields  to  none  in  the  amount  of  original  and  borrowed  | 

The  subscription  price  of  the  "American  Journal  of  the  Medical  Sciences"  has 
never  been  raised,  during  its  long  career.  It  is  still  Five  Dollars  per  annum ;  and 
when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  "Medical  News  and 
Library,"  making  in  all  about  1500  large  octavo  pages  per  annum,  free  of  postage. 

II. 

THE  MEDICAL  1ST.WS  AND  LIBRARY 

is  a  monthly  periodical  of  Thirty-two  large  octavo  pages,  making  384  pages  per 
annum.  Its  "News  Department"  presents  the  current  information  of  the  day,  with 
Clinical  Lectures  and  Hospital  Gleanings;  while  the  "Library  Department"  is  de- 
voted to  publishing  standard  works  on  the  various  branches  of  medical  science,  paged 
separately,  so  that  they  can  be  removed  and  bound  on  completion.  In  this  manner 
subscribers  have  received,  without  expense,  such  works  as  "  Watson's  Practice," 
"  Todd  and  Bow.man's  Physiology,"  "West  on  Children,"  " Malgaigne's  Surgery," 
&c.  &c.     And  with  January  1873  will  be  commenced  the  publication  of  Dr.  McCall 

»  <;.iinn!unication8  are  invited  from  gentlemen  in  all  pane  of  the  cooniry.  Elaborate  uriiilee  lagerted 
by  the  Editor  Are  paid  for  by  cue  Pablistier. 


Henry  C.  Lea's  Publications — (Am.  Journ.  Med.  Sciences). 


AiNDERSON's  new  work  "On  tiik  Tkeatmknt  of  Diskases  of  the  Skix,  with  a.n  Ana- 
lysis OF  Kl.KVEN  'I'llOUSAND  CoNRKCUTIVE  CaSKS." 

As  stated  above,  the  subscription  price  of  the  "Medical  News  and  Library"  is 
One  Dollar  per  annum  in  advance;  and  it  is  furnished  without  charo-e  to  all  advance 
paying  subscribers  to  the  "American  Journal  of  the  Medical  Sciences." 

III. 

THE  HALF-YEARLY  ABSTRACT  OF  THE  MEDICAL  SCHoNCES 

is  issued  in  half-yearly  volumes,  which  will  be  delivered  to  subscribers  about  the  first 
of  February,  and  First  of  August.  P^ach  volume  contains  about  300  closely  printed 
octavo  pages,  making  about  six  hundred  pages  per  annum. 

"Ranking's  Abstract"  has  now  been  published  in  England  regularly  for  more  than 
twenty  years,  and  has  acquired  the  highest  reputation  for  the  ability  and  industry 
with  which  the  essence  of  medical  literature  is  condensed  into  its  pages.  It  pur- 
ports to  be  "-4  Digest  of  British  and  Continental  Mtdicine,  and  of  the  Progress  of 
Medicine  and  the  Collateral  Sciences,"  and  it  is  even  more  than  this,  for  America  is 
largely  represented  in  its  pages.  It  draws  its  material  not  only  from  all  the  leading 
American,  British,  and  Continental  journals,  but  also  from  the  medical  works  and 
treatises  issued  during  the  preceding  six  months,  thus  giving  a  complete  digest  of 
medical  progress.  Each  article  is  carefully  condensed,  so  as  to  present  its  substance 
in  the  smallest  possible  compass,  thus  affording  space  for  the  very  large  amount  of  infor- 
mation laid  before  its  readers.     The  volumes  of  1872,  for  instance,  have  contained 

SIXTY-FOUR  ARTICLES  ON  GENERAL  QDESTIONS  IN  MEDICINE. 

NiNETY-SIX  ARTICLES  ON  SPECIAL  QUESTIONS  IN  MEDICINE. 

TWELVE  ARTICLES  ON  FORENSIC  MEDICINE. 

NINETY  THREE  ARTICLES  ON  THERAPEUTICS. 

FORTY-TWO  ARTICLES  ON  GENERAL  QUESTIONS  IN  SURGERY. 

ONE  HUNDRED  AND  THIRTY-THREE  ARTICLES  ON  SPECIAL  QUESTIONS  IN  SURGERY 

EIGHTY  ARTICLES  ON  MIDWIFERY  AND  DISEASES  OF  VS^OMEN  AND  CHILDREN 

EIGHTEEN  ARTICLES  IN  APPENDIX. 

Making  in  all  nearly  five  hi\ndred  and  fifty  articles  in  a  single  year.  Each  volume, 
moreover,  is  systematically  arranged,  with  an  elaborate  Table  of  Contents  and  a  very 
full  Index,  thus  facilitating  the  researches  of  the  reader  in  pursuit  of  particular  sub- 
jects, and  enabling  him  to  refer  without  loss  of  time  to  the  vast  amount  of  information 
contained  in  its  pages. 

The  subscription  price  of  the  "Abstract,"  mailed  free  of  postage,  is  Two 
Dollars  and  a  Half  per  annum,  payable  in  advance.     Single  volumes,  $1  50  each. 

As  stated  above,  however,  it  will  be  supplied  in  conjunction  with  the  "Amerk^an 
Journal  of  the  Medical  Sciences"  and  the  "Medical  News  and  Library,"  the 
whole/ree  of  postage,  for  Six  Dollars  per  annum  in  advance. 

For  this  small  sum  the  subscriber  will  therefore  receive  three  periodicals  costing 
separately  Eight  Dollars  and  a  Half,  each  of  them  enjoying  the  highest  reputation  in 
its  class,  containing  in  all  over  two  thousand  pages  of  the  choicest  reading,  and  pre- 
senting a  complete  view  of  medical  progress  throughout  both  hemispheres. 

In  this  effort  to  bring  so  large  an  amount  of  practical  information  within  the  reach 
of  every  member  of  the  profession,  the  publisher  confidently  anticipates  the  friendly 
aid  of  all  who  are  interested  in  the  dissemination  of  sound  medical  literature.  He 
trusts,  especially,  that  the  subscribers  to  the  "American  Medical  Journal"  will  call 
the  attention  of  their  acquaintances  to  the  advantages  thus  offered,  and  that  he  will 
be  sustained  in  the  endeavor  to  permanently  establish  medical  periodical  literature  on 
a  footing  of  cheapness  never  heretofore  attempted. 

rilEMlUM  FOR  NEW  SLBSCBIBEBS. 

Any  gentleman  who  will  remit  tlie  amount  for  two  subscriptions  for  1873,  one  of 
which  must  be  for  a  new  subscriber,  will  receive  as  a  premium,  free  by  mail,  a  copy  of 
the  new  edition  of  Tanner's  Clinical  Manual,  for  advertisement  of  which  see  p.  .o, 
or  of  Chambers'  Restorative  Medicine  (see  p.  17),  or  West  on  Nervous  Disorders 
OF  Children  (see  p.  21). 

*^*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1873,  as  the  constant  increase  in  the  subscription  list  almost 
always  exhausts  the  quantity  printed  shortly  after  publication. 

t^  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  tne  order  ol  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"Journal"  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  in  reqistkred 
letters.     Address, 

HENRY  C.  LEA, 
Nob.  706  and  708  Sansom  St.,  Philadelphia,  Pa. 


Henry  C.  Lea's  Publications — {Dictionaries). 


jyUNGLISON  [ROBLEY),  31. D., 

Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

MEDICAL   LEXICON;   A  Dictionary   of  Medical  Science:    Con- 
taining a  concise  eKplanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.     Notices  of  Climate  and  of  Mineral  Waters;   Formulae  for 
Officinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.    Thoroughly  Revi.'^ed,  and  very  greatly  Modified  and  Augmented. 
In  one  very  large  and  handsome  royal  octavo  volume  of  1048  double-columned  pages,  in 
small  type ;  strongly  done  up  in  extra  cloth,  $6  00  ;  leather,  raised  bands,  $li  75. 
The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a  condensed  view  of  its  various  medical  relatiom, 
and  thus  to  render  the  work  an  epitome  of  the  exi.'iting  condition  of  medicnl  science.     Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken.     The  mechanical  exe- 
cution of  this  edition  will  be  found  greatly  superior  to  that  of  previous  impressions.    By  enlarging 
the  size  of  the  volume  to  a  royal  octavo,  and  by  the  employment  of  a  small  but  clear  type,  on 
extra  fine  paper,  the  additions  have  been  incorporated  without  materially  increasing  the  bulk  ni 
the  volume,  and  the  matter  of  two  or  three  ordinary  octavos  has  been  compressed  into  the  space 
of  one  not  unhandy  for  consultation  and  reference. 

It  is  undoubtedly  the  mcst  complete  and  useful 
medical  dictionary  liitberto  published  in  this  country. 
— Ohicago  Med.  Examiner,  February,  1*6:5. 


It  would  \>f  a  work  of  Bupererogation  to  bestow  a 
word  of  praise  upon  this  Lexicon.  We  can  only 
wonder  at  the  labor  expended,  for  whenever  we  refer 
to  its  pages  for  information  we  are  seldom  disap- 
pointed in  finding  all  we  desire,  whether  it  be  in  ac- 
centuation, etymology,  or  definition  of  terms. — New 
York  MedicalJournal ,  November,  lSt).5. 

It  would  be  mere  waste  of  words  in  us  to  express 
our  admiration  of  a  work  which  is  so  universally 
and  deservedly  appreciated.  The  most  admirable 
work  of  its  kind  in  the  English  language.  As  a  buck 
of  reference  it  is  invaluable  to  the  medical  practi- 
tioner, and  in  every  instance  that  we  have  turned 
over  its  pages  for  information  we  have  been  charmed 
by  the  clearness  of  lauguage  and  the  accuracy  of 
detail  with  which  each  abounds.  We  can  most  cor- 
dially and  confidently  commend  it  to  our  readers. — 
Glasgow  MedicalJournal,  January,  ISGti. 

A  work  to  which  there  is  no  equal  in  the  English 
lauguage. — Edinburgh  Medical  Journal. 

It  is  something  more  than  a  dictionary,  and  some- 
thing less  than  an  encyclopsedia.  This  edition  of  the 
well-known  work  is  a  great  improvement  on  its  pre- 
decessors. The  book  is  one  of  the  very  few  of  which 
It  may  be  said  with  truth  that  every  medical  man 
should  possess  it. — London  Medical  Tinies,  Aug.  26, 

Few  works  of  the  class  exhibit  a  grander  monument 
of  patient  research  and  of  scientific  lore.  The  extent 
of  the  sale  of  this  lexicon  is  suUicient  to  testify  to  its 
u.-^efulness,  and  to  the  great  service  conferred  by  Dr. 
Eubley  Dunglison  on  the  profession,  and  indeed  on 
others,  by  its  issue. — London  Lancet,  May  13,  1865. 

The  old  edition,  which  is  now  superseded  by  the 
new,  has  been  universally  looked  upon  by  the  medi- 
cal profession  as  a  work  of  immense  research  and 
great  value.  The  new  has  increased  usefulness;  for 
medicine,  in  all  its  branches,  has  been  making  such 
progress  that  many  new  terms  and  subjects  Lave  re- 
cently been  introduced  :  all  of  which  may  be  found 
fully  defined  in  the  present  edition.  We  know  of  no 
other  dictionary  in  the  English  language  that  can 
bear  a  comparison  with  it  in  point  of  completeness  of 
subjects  and  accuracy  of  statement. — N.  Y.  Jjrug- 
gt.its'  Circular,  ISbo. 

For  many  years  Dunglison's  Dictionary  has  been 
the  standard  book  of  reference  with  most  practition- 
ers in  this  country,  and  we  can  certainly  commend 
this  work  to  the  renewed  confidence  and  regard  of 
aur  readers. — Cindnnaii  LiirLCtt,  April,  lS6o. 


What  we  take  to  be  decidedly  the  best  medical  dic- 
tionary in  the  English  language.  The  present  edition 
is  brought  fully  up  to  the  advanced  state  of  science. 
For  many  a  long  year  "  Dunglison  "  has  been  at  our 
elbow,  a  constant  companion  and  friend,  and  we 
greet  him  in  his  replenished  and  improved  form  with 
especial  satisfaction. — Pacific  Med.  and  Snrg.  Jour- 
nal, June  27,  1S6.5. 

This  is,  perhaps,  the  book  of  all  others  which  the 
physician  or  surgeon  should  have  on  his  shelves.  It 
is  more  needed  at  ihe  present  day  than  a  few  years 
back. — Canada  Med.  Journal,  July,  1865. 

It  deservedly  stands  at  the  head,  and  cannot  be 
surpas.sed  in  excellence. — Buffalo  Med.  and  Surg. 
Journal,  April,  1S65. 

We  can  sincerely  commend  Dr  Dunglison's  work 
as  most  thorough,  scientific,  and  accurate.  We  have 
tested  it  by  searching  its  pages  for  new  terms,  which 
have  abounded  so  much  of  late  in  medical  nomen- 
clature, and  our  search  has  been  successful  in  every 
instance.  We  have  been  particularly  struck  with  the 
fulness  of  the  synonymy  and  the  accuracy  of  the  de- 
rivation of  words.  It  is  as  necessary  a  work  to  every 
enlightened  physician  as  Worcester's  English  Dic- 
tionary is  to  every  one  who  wonld  keep  up  his  knowl- 
edge of  the  English  tongue  to  the  standard  of  the 
present  day.  It  is,  to  our  mind,  the  most  complete 
work  of  the  kind  with  which  we  are  accinainted. — 
Boston,  Med.  and  Surg.  Journal,  June  22,  1&65. 

We  are  free  to  confess  that  we  know  of  no  medical 
dictionary  more  complete;  no  one  better,  if  so  well 
adapted  for  the  use  of  the  student;  no  one  that  may 
be  consulted  with  more  satisfaction  by  the  medical 
practitioner. — Am.  Jour.  Med.  Sciences,  .^pril,  Ibiia. 

The  value  of  the  pre.sent  edition  has  been  greatly 
enhanced  by  the  introduction  of  new  subjects  and 
terms,  and  a  more  complete  etymology  aiiU  accentua- 
tion, which  renders  the  work  not  only  satisfactory 
and  desirable,  but  indispensable  to  the  physician. — 
Ohicago  Med.  Journal,  April,  1S60. 

No  intelligent  member  of  the  pr.jfession  can  or  wi  il 
be  without  it. — St.  Louis  Mett.  and  Surg.  Journal, 
April,  IStio. 

It  has  the  rare  merit  that  it  certaiuly  has  no  rival 
in  the  English  language  for  accuracy  ani  extent  of 
references. — London  Medical  Gazette. 


LJOBLYN  [RICHARD  D.),  M.D. 

A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.  Revi.sed,  with  numeroui-  additions,  by  I.saac  Hays, 
M.D.,  Editor  of  the  "  American  Journal  of  the  Medical  Sciences."  In  one  large  royal 
12mo.  volume  of  over  60(1  double-columned  pages  ;  extra  cloth,  $1   50  ;  leather,  S'2  00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  tlie  student's  labia. — Sc  lUfv.rn 
tSed.  and  Surg.  Journal 


Heney  C.  Lea's  Publications — (Manuals). 


]\JEILL  {JOHN),  M.D.,    and     j^MITR  {FRANCIS  G.),  M.D., 

•^  »  '^-'     Pr'if.  of  the.  Inntitrdes  (if  'Mf.dirine.  in  the  Univ.  of  Penna. 

AN    ANALYTICAL    COMPENDIUM    OP   THE    VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.  A 
new  e.iition,  revised  and  improved.  In  one  very  large  and  hand.somely  printed  royal  12mc. 
volume,  of  about  one  thou.«and  pages,  with  374  wood  cuts,  extra  cloth,  $4  ;  strongly  bound 
in  leather,  with  raised  bands,  $4  75. 


The  Compend  of  Drs.  N^'illand  Smith  Ik  incompara- 
bly the  most  valiiableworkof  itsclawn  evpr  published 
In  this  couutry  Attempts  havebeeu  made  iu  various 
quarters  to  squeeze  Anatomy,  Physiology,  Surgery, 
the  Practice  of  Medicine,  Obstetrics,  Maieria  Medica, 
and  Chemistry  into  a  single  manual;  but  the  opera- 
tion has  signally  failed  in  the  hands  of  all  up  to  the 
advent  of"  Neill  and  Smith's"  volume,  which  is  quite 
a  miracle  of  success.  The  outlines  of  the  whole  are 
admirably  drawn  and  illustrated,  and  the  authors 
are  eminently  entitled  to  the  grateful  consideration 
of  the  student  of  every  class.— iV.  0.  Mad.  and  Surg. 
Journal. 

There  are  but  few  students  or  practitioners  of  me- 
dicine unacquainted  with  the  former  editions  of  this 
anassuming  though  highly  Instructive  work.  The 
whole  science  of  medicine  appears  to  have  been  sifted, 
as  the  gold-bearing  sands  of  EI  Dorado,  and  the  pre- 


cious facts  treasured  up  In  this  little  volume.  A  com- 
plete portable  library  so  condensed  that  the  student 
may  make  it  his  constant  pocket  companion. —  West- 
urn  L'incet. 

In  the  rapid  coarse  of  lectures,  where  work  for  the 
students  is  heavy,  and  review  necessary  for  an  exa- 
mination, a  compend  is  not  only  valuable,  but  it  is 
almost  a  Sine '/?t«  ?iort.  The  one  before  us  is,  in  most 
of  the  divisions,  the  most  unexceptionable  of  all  booVs 
of  the  kind  that  we  know  of.  Of  course  it  is  uselefs 
for  us  to  recommend  it  to  all  last  course  students,  bnt 
there  is  a  class  to  whom  we  very  sincerely  commend 
this  cheap  book  as  worth  its  weight  in  silver — that 
class  is  the  graduates  in  medicine  of  more  than  ten 
years'  standing,  who  have  not  studied  medicine 
since.  They  will  perhaps  find  out  from  it  that  the 
science  is  not  exactly  now  what  it  was  when  they 
left  it  off.  — r/ie  Stethoscope. 


TTARTSHORNE  {HENRY),  M.  D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    OF    THE    MEDICAL    SCIENCES;    containing 

Handbooks  on   Anatomy,   Physiology,  Chemistry,  Materia   Medica,    Practical   Medicine, 
Surgery,  and  Obstetrics.     In  one  large  royal  12rao.  volume  of  1000  clo.sely  printed  pages, 
with  over  300  illustrations  on  wood,  extra  cloth,  $4  50  ;    leather,   raised  bands,  $5  2ft. 
{Lntehj  Puhlished.) 
The  ability  of  the  author,   and  his  practical  skill  in  condensation,  give  assurance  that  this 
work  will  prove  valuable  not  only  to  the  student  preparing  for  examination,  but  also  to  the  prac- 
titioner desirous  of  obtaining  within  a  moderate  compass,  a  view  of  the  existing  condition  of  the 
various  departments  of  science  connected  with  medicine. 

less  valuable  to  the  beginner.  Every  medical  student 
who  desires  a  reliable  refresher  to  his  memory  whea 
the  pressure  of  lectures  and  other  col  lege  work  crowds 
to  prevent  him  from  having  an  opportunity  to  drink 
deeper  iu  the  larger  works,  will  find  this  one  of  th« 
greatest  utility.  It  is  thoroughly  trustworthy  from 
beginning  to  end;  and  as  we  have  before  intimated, 
a  remarkably  truthful  outline  sketch  of  the  present 
slate  of  medical  science.  We  could  hardly  expect  it 
should  be  otherwise,  however,  under  the  charge  of 
such  a  thorough  medical  scholar  as  the  author  has 
already  proved  himself  to  be. — N.  York  Med.  Record, 
March  1.5,  1869. 


This  work  is  a  remarkably  complete  one  in  its  way, 
and  comes  nearer  to  our  idea  of  what  a  Conspectus 
gbo^jld  be  than  any  we  have  yet  seen.  Prof.  Harts- 
horne,  with  a  commendable  forethought,  intrusted 
the  preparation  of  many  of  the  chapters  on  special 
subjects  to  experts,  reserving  only  anatomy,  physio- 
logy, and  practice  of  medicine  to  himself.  As  a  result 
we  have  every  department  worked  up  to  the  latest 
dale  and  in  a  refreshingly  concise  and  lucid  manner. 
There  are  an  immense  amount  of  illustrations  scat- 
tered throughout  the  work,  and  although  they  have 
often  been  seen  before  in  the  various  works  upon  gen- 
eral and  special  subjects,  yet  they  will  be  none  the 


T  UDLOW  {J.L.),  M.D. 
A   MANUAL   OF   EXAMINATIONS   upon   Anatomy,   Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  extra  cloth,  $3  25;  leather,  $3  75. 
The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  office  examination  of  students,  and  for  those  preparing  for  graduation.  * 

rfANNER  {THOMAS  HA  WKES),  M.  D.,  ^-c. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.     Third  Americ.m  from  the  Second  London  Edition.     Revised  and  Enlarged  bf 

Tilbury  Fox,  M.  D.,  Physician  to  the  Skin   Department  in  University  College  Hospital, 

&c.    In  one  neat  volume  small  12mo.,  of  about  375  pages,  extra  cloth.   $150.    (jfust  Iss2ce,d.) 

*;)(:*  By  reference  to  the  "  Prospectus  of  Journal"  on  page  3,  it  will  be  seen  that  this  work  13 

offered  as  a  premium  for  procuring  new  subscribers  to  the  "American  Journal  of  the  Medicai. 

Sciences." 

The  objections  commonly,  and  justly,  urged  against 
the  general  run  of  " compend s,"  "conspectuses,"  and 
other  aids  to  indolence,  are  not  applicable  to  this  little 
volume,  which  contains  in  concise  phrase  just  those 
practical  details  that  are  of  most  use  in  daily  diag- 
nosis, but  which  the  young  practitioner  finds  it  difll- 
cult  to  carry  always  in  his  memory  without  some 
quickly  accessible  means  of  reference.  Altogether, 
I  he  book  is  one  which  we  can  heartily  commend  lo 
those  who  have  not  opportunity  for  extensive  read- 
ing, or  who,  having  read  much,  still  wish  an  occa- 
sional practical  reminder. — N.  Y.  Med.  Gazette,  Nov. 
10,  1870. 


Taken  as  a  whole,  it  is  the  most  compact  vade  me- 
cum  for  the  use  of  the  advanced  student  and  junior 
practitioner  with  which  we  are  acquainted. — Boston 
Med.  and  Surg.  Journal,  Sept.  22,  1870. 

It  contains  so  much  that  is  valuable,  presented  in 
80  attractive  a  form,  that  it  can  hardly  be  spared 
even  iu  the  presence  of  more  full  and  complete  works. 
The  additions  made  to  the  volume  by  Mr.  Fox  very 
materially  enhance  its  value,  and  almost  make  it  a 
new  work.  Its  convenient  size  makes  it  a  valuable 
companion  to  the  country  practitioner,  and  if  con- 
stantly carried  by  him,  would  often  render  him  good 
service,  and  relieve  many  a  doubt  and  perplexity. — 
It^aventoorth  Med.  Herald,  July,  1870. 


6  .  Henry  C.  Lea's  Publications — {Anatomy). 


pRAY  [HENRY),  F.R.S., 

^^  Lecturer  on  Anatomy  at  St.  George's  Hospital,  London. 

ANATOMY,    DESCRIPTIVE    AND    SURGICAL.      The  Drawinprs  by 

H.  V.  Carter,  M.  D.,  late  Demonstrator  on  Anatomj'  at  St.  George's  Hospital ;  the  Dissec- 
tions jointly  by  the  Author  and  Dr.  Carter.     A  new  American,  from  the  fifth  enlarged 
and  improved  London  edition.     In  one  magnificent  imperial  octavo  volume,  of  nearly  900 
pages,  with  4fi6  large  and  elaborate  engravings  on  -wood.     Price  in  extra  cloth,  $6  00  ; 
leather,  raised  bands,  $7  00.      (Just  Issued.) 
The  author  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.     The  en- 
gravincs  form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
fiffures  of  reference,  with  descriptions  at  the  foot.    They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Notwithstanding  the  enlargement  of  this  edition,  it  has  been  kept  at  its  former  very  moderate 
price,  rendering  it  one  of  the  cheapest  works  now  before  the  profession. 

The  illustrations  are  beautifully  executed,  and  ren- 
der this  work  an  indispensable  adjanct  to  the  library 
of  the  surgeon.  This  remark  applies  with  great  foice 
to  those  surgeons  practising  at  a  distance  from  our 
large  cities,  as  the  opportunity  of  refreshing  their 
memory  by  actual  dissection  is  not  always  attain- 
able—(7anf"?tf  Med  Journal,  Aug.  1870. 

The  work  is  too  well  known  and  appreciated  by  the 
profession  to  need  any  comment.  No  medical  man 
c^n  afford  to  be  without  it,  if  its  only  merit  were  to 
serve  as  a  reminder  of  that  which  so  soon  becomes 
forgotten,  when  not  called  into  frequent  use,  viz  ,  the 
relations  and  names  of  the  complex  organism  of  the 
human  body.  The  present  edition  is  much  improved. 
—Californin  Jlled.  Gazette,  July,  1870. 


From  time  to  time,  as  snccessive  editions  have  ap- 
peared, we  have  had  much  pleasure  in  expressing 
the  general  judgment  of  the  wonderful  excellence  of 
Gray's  Anatomy. — Cincinnati  Lancet,  July,  1870. 

Altogether,  it  is  unquestionably  the  most  complete 
and  serviceable  text-book  in  anatomy  that  has  ever 
been  presented  to  the  student,  and  forms  a  striking 
contrast  to  the  dry  and  perplexing  volumes  on  the 
same  subject  through  which  their  predecessors  strug- 
gled in  days  gone  by. — N.  Y.  Med.  Record,  June  15, 
1870. 

To  commend  Gray's  Anatomy  to  the  medical  pro- 
fession is  almost  as  much  a  work  of  supererogation 
as  it  would  be  to  give  a  favorable  notice  of  the  Bible 
in  the  religious  press  To  say  that  it  is  the  most 
Gray's  Anatomy  has  been  so  long  the  standard  of  j  complete  and  conveniently  arranged  text  book  of  its 


perfection  with  every  student  of  anatomy,  that  we 
need  do  no  more  than  call  attention  to  the  improve- 
ment in  the  present  edition. — Detroit  Review  of  Med. 
and  Pharm.,  Aug.  1S70. 


kind,  is  to  repeat  what  each  generation  of  students 
has  learned  as  a  tradition  ff  thf  elders,  and  verified 
by  personal  experience. — N.  Y.  Med.  Gazette,  Doe. 
17,  1870. 


(^MITH  {HENRY n.),  M.D.,         and     TJORNER  (  WILLIAM  E.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna.,  &c.  Late  Prof .  of  Anatomy  in  the  Univ.  of  Penna.,  &e. 

AN    ANATOMICAL    ATLAS,  illustrative   of  the   Structure  of  the 

Human  Body.     In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  sis  hundred 

and  fifty  beautiful  figures.     $4  60. 

The  plan  of  this  Atlas,  which  renders  it  so  pecu-  the  kind  that  has  yet  appeared;  and  we  must  add, 

liarly  convenient  for  the  student,  and  its  superb  ar-  the  very  beautiful  manner  in  which  it  is  "got  up," 

tistical  execution,  have  been  already  pointed  out.  We  is  so  creditable  to  the  country  as  to  be  flattering  to 

must  congratulate  the  student  upoa  the  completion  our  national  pride. — American  MedicalJournal. 
of  this  Atlas,  as  it  is  the  most  convenient  work  of 


(^HARPEY  ( WILLIA3I),  M.D.,     and      Q  UAIN  [JONES  ^  RICHARD). 
HUMAN  ANATOMY.   Revised,  with  Notes  and  Additions,  by  Joseph 

Leidy,  M.D.,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.     Complete  in  two 
large  octavo  volumes,  of  about  1300  pages,  with  611  illustrations;  extra  cloth,  $6  00. 

The  very  low  price  of  this  standard  work,  and  its  completeness  in  all  departments  of  the  subject, 
should  command  for  it  a  place  in  the  library  of  all  anatomical  students. 


jrODGES,  [RICHARD  M.),  M.D., 

J- J-  Late  De.monstrator  of  Anatomy  in  the  Medical  Department  of  Harvard.  University. 

PRACTICAL  DISSECTIONS.     Second  Edition,  thoroughly  revised.     In 

one  neat  royal  12mo.  volume,  half-bound,  $2  00. 

The  object  of  this  work  is  to  present  to  the  anatomical  student  a  clear  and  concise  description 
of  that  which  he  is  expected  to  observe  in  an  ordinary  couise  of  dissections.  The  author  has 
endeavored  to  omit  unnecessary  details,  and  to  present  the  subje  jl  in  the  form  which  many  years' 
experience  has  shown  him  to  be  the  most  convenient  and  intelligible  to  the  student.  In  the 
revision  of  the  present  edition,  he  has  sedulously  labored  to  render  the  volume  more  worthy  of 
tile  favor  with  which  it  has  heretofore  been  received. 


Henry  C.  Lea's  Publications — {Anatomy). 


-irriLSON  [ERASMUS),  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.     Edited 

by  W.  11.  QoBKECHT,  M.  D.,  Professor  of  Generalaud  Surgical  Anatomy  in  tlje  Medical  Col- 
lego  of  Ohio.     Illustrated  with  three  hundred  and   ninety-seven  engravings  on  wood.      In 
one  liirge  and  handsome  octavo  volume,  of  over  000  large  pages;  extra  cloth,  $4  00;   lea- 
ther, $1}  00. 
The  publisher  trusts  that  the  well-earned  reputation  of  this  long-established  favorite  will  be 
more  than  maintained  by  the  present  edition.     Besides  a  very  thorough  revision  by  the  author,  it 
has  been  most  carefully  examined  by  the  editor,  and  the  efl'orts  of  both  have  been  directed  to  in- 
troducing everything  which  increased  experience  in  its  use  has  suggested  as  desirable  to  render  it 
a  complete  text-book  for  those  seeking  to  sbtain  or  to  renew  an  acquaintance  with  Human  Ana- 
tomy.    The  amount  of  additions  which  it  has  thus  received  may  be  estimated  from  the  fact  that 
the  present  edition  contains  over  one-fourth  more  matter  than  the  last,  rendering  a  smaller  type 
and  an  enlarged  page  reciuisite  to  keep  the  volume  within  a  convenient  size.     The  author  has  not 
only  thus  added  largely  to  the  work,  but  he  has  also  made  alterations  throughout,  wherever  there 
appeared  the  opportunity  of  improving  the  arrangement  or  style,  so  as  to  present  every  fact  in  its 
most  appropriate  manner,  and  to  render  the  whole  as  clear  and  intelligible  as  possible.    The  editor 
has  exercised  the  utmost  caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely  increased 
the  number  of  illustrations,  of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition 
than  in  the  last,  thus  bringing  distinctly  before  the  eye  of  the  student  everything  of  interest  or 
importance.  

'  J-TEATH  [CHRISTOPHER),  F.  R.  C.  S., 

■^J-  Teacher  of  Oiieration  Surgery  in  University  College,  London. 

PRACTICAL   ANATOMY:    A   Manual    of  Dissections.     From   the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  Keen, 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jeiferson  Medical  College,  Philadelphia. 
In  one  handsome  royal  12mo.  volume  of  578  pages,  with  247  illustrations.  Extra  cloth, 
$3  60  ;  leather,  $4  00.      {Lately  Fublisked.) 


Dr.  Keen,  the  American  editor  of  this  work,  in  his 
preface,  says:  "in  presenting  this  American  edition 
of  'Heath's  Practical  Anatomy,'  I  feel  that  I  have 
been  instrumental  in  supplying  a  want  lung  felt  for 
a  real  dissector's  manual,"  and  thi.-,  assertion  of  its 
editor  we  deem  is  fully  justified,  after  an  examina- 
bion  of  its  contents,  for  it  is  really  an  excellent  work. 
Indeed,  we  do  not  hesitate  to  say,  the  best  of  its  class 
with  which  we  are  acquainted  ;  resembling  Wilson 
iu  terse  and  clear  description,  excelling  most  of  the 
go-called  practical  anatomical  dissectors  iu  the  scope 
of  the  subject  and  practical  selected  matter.  .  .  . 
in  reading  thie  work,  one  is  forcibly  impressed  with 
the  gi'eat  pains  the  author  takes  to  impress  the  sub- 
ject upon  the  mind  of  the  student.  He  is  full  of  rare 
and  pleasing  little  devices  to  aid  memory  in  main- 
taining its  hold  upon  the  slippery  slopes  of  anatomy. 
St.  Louis  Med.  and  Surg.  Journal,  Mar.  10,  1871. 

It  appears  to  us  certain  that,  as  a  guide  in  dissec- 
tion, and  as  a  work  containing  facts  ol  anatomy  in 
brief  and  easily  understood  lurm,  this  manual  is 
ciimplete.  This  work  contains,  also,  very  perfect 
illustrations  of  parts  which  can  thus  be  mure  easily 
understood  and  studied;  in  this  respect  it  compares 
favorably  with  works   of  much   greater  pretension. 


Such  manuals  of  anatomy  are  always  favorite  works 
with  medical  students.  We  would  earnestly  recom- 
mend this  one  to  their  attention;  it  has  excellences 
which  make  it  valuable  as  a  guide  in  dissecting,  as 
well  as  in  studying  anatomy. — Jiuffaio  Medical  and 
Surgical  Journal,  Jan.  ISVl. 

The  first  English  edition  was  issued  about  six  years 
ago,  and  was  favorably  received  not  only  on  account 
of  the  great  reputation  of  its  author,  but  also  from 
its  great  value  and  excellence  as  a  guide-book  to  the 
practical  anatomist.  The  American  edition  has  un- 
dergone some  alterations  and  additions  which  will 
no  doubt  enhance  its  value  materially.  The  conve- 
nience of  the  student  has  been  carefully  consulted  in 
the  arrangement  of  the  text,  and  the  directions  given 
for  the  prosecution  of  certain  dissections  will  be  duly 
appreciated. — Canada  Lancet,  Feb.  li)71. 

This  is  an  excellent  Dissector's  Manual ;  one  which 
is  not  merely  a  descriptive  manual  of  anatomy,  but 
a  guide  to  the  student  at  the  dissecting  table,  enabling 
him,  though  a  beginner,  to  prosecute  his  work  intel- 
ligently, and  wituout  assistance.  The  American  edi- 
tor has  made  many  valuable  alterations  and  addi- 
tions to  the  original  work. — Am.  Journ.  of  Obstetrics, 
Feb.  1S71. 


MACLISE  [JOSEPH). 

SURGICAL   ANATOMY^      By  Joseph  Maclise,  Surgeon.     In  one 

volume,  very  large  imperial  quarto;  with  68  large  and  splendid  plates,  drawn  in  the  best 
style  and  beautifully  colored,  containing  190  figures,  many  of  them  the  size  ot  lite;  together 
with  copious  explanatory  letter-press.      Strongly  and  handsomely  bound  in  extra  cloth. 
Price  f  14  00. 
As  no  complete  work  of  the  kind  has  heretofore  been  published  in  the  English  language,  the 
present  volume  will  supply  a  want  long  felt  in  this  country  of  an  accurate  and  comprehensive 
Atlas  of  Surgical  Anatomy,  to  which  the  student  and  practitioner  can  at  all  times  refer  to  ascer- 
tain the  exact  relative  positions  ol  the  various  portions  of  the  human  frame  towards  each  other 
and  to  the  surface,  as  well  as  their  abnormal  deviations.     Notwithstanding  the  large  size,  beauty 
and  finish  of  the  very  numerous  illustrations,  it  will,  be  observed  that  the  price  is  so  low  as  to 
place  it  within  the  reach  of  all  members  of  the  profession. 

We  know  of  no  work  on  surgical  anatomy  which    refreshed   by  those   clear  and  distinct  dissections, 
can  compete  with  it. — Lancet. 

The  work  of  Maclise  on  surgical  anatomy  is  of  the 
highest  value.  In  some  respects  it  is  the  best  publi- 
cation of  its  kind  we  have  seen,  and  is  worthy  of  a 
place  in  the  libiary  of  any  medical  man,  while  the 
student  could  scarcely  make  a  better  investment  than 
this. — The  Western  Journal  of  Medicine  and  Surgery. 

No  such  lithographic  illustrations  of  surgical  re- 
gions have  hitherto,  we  think,  been  given.     While 


the  operator  is  shown  every  vessel  and  nerve  where 
an  operation  is  contemplated,  the  exact  anatomist  is 


which  every  one  must  appreciat.e  wUo  has  a  particle 
of  enthusiasm.  The  English  medical  press  has  quite 
exhausted  the  words  ot  pz-aise,  in  recommending  this 
admirable  treatise.  Those  who  ha»e  any  curiosity 
to  gratify,  in  reference  to  the  perfectibility  of  the 
lithographic  art  in  delineating  the  complex  mechan- 
ism of  the  human  body,  are  invited  to  examine  our 
specimen  copy.  If  anything  will  induce  surgeons 
and  students  to  patronize  a  book  of  such  rare  value 
and  everyday  importance  to  them,  it  will  be  a  survey 
of  the  artistical  skill  exhibited  in  these  fac-similes  of 
nature. — Boston  Med.  and  Surg.  Journal. 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOLOGY.  1 
Eighth  edition,  extensively  revised  and  modified.  1 


In  2  vols.  8vo.,  of  over  1000  pages,  with  more  than 
300  Wood-cuts  ;  extra  cloth,  ^\i  Oo. 


8 


Henry  C.  Lea's  Publications — (Physiology). 


lU'ARSHALL  {JOHN),  F.  R.  S., 

J.tL  Pro/tssor  of  Surgery  in  University  College,  London,  Ae. 

OUTLINES  OF  PHYSIOLOGY,  HUMAN  AND  COMPARATIVE. 

"With  Additions  by  Francis  Gurnet  Smith,  M.  D.,  Professor  of  the  Institutes  of  Medi- 
cine in  the  University  of  Pennsylvania,  Ac.  With  numerous  illustrations.  In  one  large 
and  handsome  octavo  volume,  of  1026  pages,  extra  cloth,  $6  60  ;  leather,  raised  bands, 

$7  60. 


In  fact,  in  every  respect,  Mr.  Marshall  has  present- 
ed U8  with  a  most  complete,  reliable,  and  scientific 
work,  and  we  feel  that  it  is  worthy  our  warmest 
commendation. — St.  Louis  Med.  Reporter,  Jan.  1S69. 

This  is  an  elaborate  and  carefully  prepared  digest 
of  human  and  comparative  physiology,  designed  lor 
the  use  of  general  readers,  but  more  especially  ser- 
viceable to  the  student  of  medicine.  Its  style  is  con- 
cise, clear,  and  scholarly;  its  order  perspicuous  and 
exact,  and  its  range  of  topics  extended.  The  author 
and  his  American  editor  have  been  careful  to  bring 
to  the  illustration  of  the  subject  the  important  disco- 
veries of  modern  science  in  the  various  cognate  de- 
partments of  investigation.  This  is  especially  visible 
in  the  variety  of  interesting  information  derived  from 
the  departments  of  chemistry  and  physics.  The  great 
amount  and  variety  of  matter  contained  in  the  work 
is  strikingly  illustrated  by  turning  over  the  copious 
index,  covering  twenty-four  closely  printed  pages  in 
double  columns. — Sillirnan's  Journal,  Jan.  1869. 

We  doubt  if  there  is  in  the  English  language  any 
compend  of  physiolugy  more  useful  to  the  student 
than  this  work. — St.  Louis  Med.  and  Surg.  Journal, 
Jan.  1869. 

It  quite  fulfils,  in  our  opinion,  the  author's  design 
of  making  it  U\i\y  educational  in  its  character — which 
is.  perhaps,  the  highest  commendation  that  can  be 
asked. — Am.  Journ.  Med.  Sciences,  Jan.  1869. 

We  may  now  congratulate  him  on  having  com- 
pleted the  latest  as  well  as  the  best  summary  of  mod- 


ern physiological  science,  both  human  and  compara- 
tive, with  which  we  are  acquainted.  To  speak  of 
this  work  in  the  terms  ordinarily  used  on  such  occa- 
sions would  not  be  agreeable  to  ourselves,  and  would 
fail  to  do  justice  to  its  author.  To  write  such  a  book 
requires  a  varied  and  wiJe  range  of  knowledge,  con- 
siderable power  of  analysis,  correct  judgment,  skill 
in  arrangement,  and  conscientious  spirit.  It  must 
have  entailed  great  labor,  but  now  that  the  task  has 
been  fuldl  led,  the  book  will  prove  not  only  invaluable 
to  the  student  of  medicine  and  surgery,  but  service- 
able to  all  candidates  in  natural  science  examinations, 
to  teachers  in  schools,  and  to  the  lover  of  nature  gene- 
rally. In  conclusion,  we  can  only  express  the  con- 
viction that  the  merits  of  the  work  will  command  for 
it  that  success  which  the  ability  and  vast  labor  dis- 
played in  its  production  so  well  deserve. — London 
Lancet,  Feb.  22,  1868. 

If  the  possession  of  knowledge,  and  peculiar  apti- 
tude and  skill  in  expounding  it,  qualify  a  man  to 
write  an  educational  work,  Sir.  Marshall's  treatise 
might  be  reviewed  favorably  without  even  opening 
the  covers.  There  are  few,  if  any,  more  accomplished 
anatomists  and  physiologists  than  the  distinguished 
professor  of  surgery  at  University  College  ;  and  ha 
has  long  enjoyed  the  highest  reputation  as  a  teacher 
of  physiology,  possessing  remarkable  powers  of  clear 
exposition  and  graphic  illustration.  We  have  rarely 
the  pleasure  of  being  able  to  recommend  a  text-book 
so  unieservedly  as  this. — British  Med.  Journal,  Jaa. 
25,  ISbS. 


nARPENTER  [WILLIAM  B.),  M.D.,  F.R.S., 

^^  Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  appli- 

cations  to  Psychology,  Pathology,  Therapeutics,  Hygiene  and  Forensic  Medicine.  A  new 
American  from  the  last  and  revised  London  edition.  With  nearlj' three  hundred  illustrations. 
Edited,  with  additions,  by  Francis  Gurney  Smith,  M.  D.,  Professor  of  the  Institutes  of 
Medicine  in  the  University  of  Pennsylvania,  <fcc.  In  one  very  large  and  beautiful  octavo 
volume,  of  about  900  large  pages,  handsomely  printed;  extra  cloth,  $5  60;  leather,  raised 
bands,  $6  60. 

With  Dr.  Smith,  we  confidently  believe  "that  the 
present  will  more  than  sustain  the  enviable  reputa- 
tion already  attained  by  former  editions,  of  being 
one  of  the  fullest  and  most  complete  treatises  on  the 
subject  in  the  English  language."  We  know  of  none 
from  the  pages  of  which  a  satisfactory  knowledge  of 
the  physiology  of  the  human  organism  can  be  as  well 
obtained,  none  better  adapted  for  the  use  of  such  as 
take  up  the  study  of  physiology  in  its  reference  to 
the  iustittites  and  practice  of  medicine. — Am.  Jour. 
Med.  Sciences. 


We  doubt  not  it  is  destined  to  retain  a  strong  hold 
on  public  favor,  and  remain  the  favorite  text-book  in 
our  colleges. —  Virginia  Medical  Journal. 

The  above  is  the  title  of  what  is  emphatically  tht 
great  work  on  physiology  ;  and  we  are  conscious  that 
it  would  be  a  useless  effort  to  attempt  to  add  any- 
thing to  the  reputation  of  this  invaluable  work,  and 
can  only  say  to  all  with  whom  our  opinion  has  any 
influence,  that  it  is  our  auihority. — Atlanta  Med. 
Journal. 


DY  THE  SAME  AUTHOR. 

PRINCIPLES  OF  COMPARATIVE  PHYSIOLOGY.    New  Ameri- 

can,  from  the  Fourth  and  Revised  London  Edition.     In  one  large  and  handsome  octayo 
volume,  with  over  three  hundred  beautiful  illustrations     Pp.752.    Extra  cloth,  $5  00. 
A.S  a  complete  and  condensed  treatise  on  its  extended  and  important  subject,  this  work  becomeg 

a  necessity  to  students  of  natural  science,  while  the  very  low  price  at  which  it  is  offered  places  it 

within  the  reach  of  all. 


f^IRKES  (  WILLIAM  SEN-HOUSE),  M.D. 

A  MANUAL  OF  PHYSIOLOGY.     A  new  American  from  the  third 

and  improved  London  edition.     With  two  hundred  illustrations.     In  one  large  and  hand- 
some royal  12mo.  volume.     Pp.  686.     Extra  cloth,  $2  25  ;  leather,  $2  75. 
It  is  at  once  convenient  in  size,  comprehensive  in  |  lent  guide  in  the  study  of  physiology  in  its  most  ad- 


design,  and  concise  in  statement,  and  altogether  well 
ttdai'ted  for  the  purpose  designed. — ^t.  Louis  Med. 
and  Surg.  Journal. 

The  physiological  reader  will  flDid  It  a  znoet  9xc«l- 


vanced  and  perfect  form.  The  author  has  showa 
himself  capable  of  giving  details  sufficiently  ampin 
in  a  condensed  and  concentrated  shape,  on  a  science 
in  which  it  is  necessary  at  once  to  be  correct  and  not 
lengthened. — Edinburgh  Med.  and-  Surg   Journal. 


Henry  C.  Lea's  Publications — (Physiology). 


9 


fiALrON  [J.  C),  M.D., 

■*-'  PrdfenKdr  of  PhyHidlogy  in  the.  CulUge.  of  Physinnnn  and  Surgeon/),  New  Torlt,  Ac. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Designed  for  the  uge 

of  Students  nnd  Practitioners  of  Medicine.  Fifth  edition,  revised,  with  nearly  three  hun- 
dred illustrations  on  wood.  In  one  very  beautiful  octavo  volume,  of  over  700  pages,  extia 
cloth,  $6  26  i  leather,  $6  25.     (Just  Issued.) 

Pre/ace  to  the  Fifth  Edition. 

In  preparing  the  present  edition  of  ttiis  work,  the  general  plan  nnd  arrangement  of  the  previous 
editions  have  been  retained,  so  far  as  thoy  have  been  found  useful  and  adapted  to  the  purposes  of 
a  text-book  for  students  of  medicine.  The  incessant  a<lvance  of  nil  the  natural  and  physical 
sciences,  never  more  active  than  within  the  last  five  ye.nrs,  has  furnished  many  valuable  aids  to 
the  special  investigations  of  the  y)hysiologist ;  and  the  progress  of  physiological  research,  during 
the  same  period,  has  required  a  careful  revision  of  the  entire  work,  and  the  modification  or  re- 
arrangement of  many  of  its  parts.  At  this  day,  nothing  is  regarded  as  of  any  value  in  natural 
science  which  is  not  based  upon  direct  and  intelligible  observation  or  experiment;  and,  accord- 
ingly, the  discussion  of  doubtful  or  theoretical  questions  has  been  avoiiled,  as  a  general  rule,  in 
the  present  volume,  while  new  facts,  from  whatever  source,  if  fully  established,  have  been  added 
nnd  incorporated  with  the  results  of  previous  investigation.  A  number  of  new  illustrations  have 
been  introduced,  and  a  few  of  the  older  ones,  which  seemed  to  be  no  longer  useful,  have  been 
omitted.  In  all  the  changes  nnd  additions  thus  made,  it  has  been  the  aim  of  the  writer  to  make  the 
book,  in  its  present  form,  a  faithful  exponent  of  the  actual  conditions  of  physiological  science. 
New  York,  October,  1871. 

In  this,  the  standard  text-book  on  Physiology,  all  that  is  needed  to  maintain  the  favor  with  which 
it  is  regarded  by  the  profession,  is  the  author's  assurance  that  it  has  been  thoroughly  revised  and 
brought  up  to  a  level  with  the  advanced  science  of  the  day.  To  accomplish  this  has  required 
some  enlargement  of  the  work,  but  no  advance  has  been  made  in  the  price. 


The  fifth  edition  of  this  truly  valuable  work  on 
Human  Physiology  comes  to  us  with  many  valuable 
improvements  and  additious.  As  a  text-book  of 
pliysiology  the  work  of  Prof.  Daltoa  has  long  been 
well  known  as  one  of  the  best  which  could  be  placed 
In  the  hands  of  student  or  practitioner.  Prof.  Dalton 
has,  in  the  several  editions  of  his  work  heretofore 
published,  labored  to  keep  step  with  the  ad  van  cement 
lo  science,  and  the  last  edition  shows  by  its  improve- 
ments on  former  ones  that  he  is  determined  to  main- 
tain the  high  standard  of  his  work.  We  predict  for 
the  present  edition  increased  favor,  though  tliis  work 
has  long  been  the  favorite  standard. — Buffalo  Med. 
and  Siirg.  Journal.,  April,  1872. 

An  extended  notice  of  a  work  so  generally  and  fa- 
vorably known  as  this  is  unnecessary.  It  is  justly 
regarded  as  one  of  the  most  valuable  text-books  on 
l;he  subject  in  the  English  language. — St.  Louis  Med. 
Archives,  May,  1872. 

We  know  no  treatise  in  physiology  so  clear,  com- 
plete, well  assimilated,  aud  perfectly  digested,  as 
Dalton's.  He  never  writes  cloudily  or  dubiously,  or 
in  mere  quotation.  He  assimilates  all  his  material, 
and  from  it  constructs  a  homogeneous  transparent 
argument,  which  is  always  honest  and  well  informed, 
and  hides  neither  truth,  ignorance,  nor  donbt,  so  far 
as  either  belongs  to  the  subject  in  hand. — Brit.  Med. 
Journal,  March  23,  1S72. 


Dr.  Dalton's  treatise  is  well  known,  and  by  many 
highly  esteemed  in  this  country.  It  is,  indeed,  a  good 
elementary  treatise  on  the  subject  it  professes  to 
teach,  aud  may  safely  be  put  into  the  hands  of  Eng- 
lish students.  It  has  one  great  merit — it  is  clear,  and, 
on  the  whole,  admirably  illustrated.  The  part  we 
have  always  esteemed  most  highly  is  that  relating 
to  Embryology.  The  diagrams  given  of  the  various 
stages  of  development  give  a  clearer  view  of  the  sub- 
ject than  do  those  in  general  use  in  this  country  ;  and 
the  text  may  be  said  to  be,  upon  the  whole,  equally 
clear. — London  Med.  Times  and  Gazette,  March  2,i, 
1872. 

Dalton's  Physiology  is  already,  and  deservedly, 
the  favorite  text-book  of  the  majority  of  American 
medical  students.  Treating  a  most  interesting  de- 
partment of  science  in  his  own  peculiarly  lively  and 
fascinating  style.  Dr.  Dalton  carries  hi.s  reader  along 
without  effort,  and  at  the  same  time  impresses  upon 
his  mind  the  truths  taught  much  more  successfully 
than  if  they  were  buried  beneath  a  multitude  of 
words. — Kansas  City  Med.  Jou.rnal,  April,  1S72. 

Professor  Dalton  is  regarded  justly  as  the  authority 
in  this  country  on  physiological  sutijecls,  and  the 
fifth  edition  of  his  valuable  work  fully  j  ustifies  the 
exalted  opinion  the  medical  world  has  of  his  labors. 
This  last  edition  is  grpatlyenlai'ged  — Virginia  Clin- 
ical Record,  April,  1S72. 


T)UNGLISON  [ROBLEY),  M.D., 

-*-^  Professor  of  In.Hitutes  of  Medicine  in  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOGY.     Eighth  edition.     Thorouohly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.     In  two 
large  and  handsomely  printed  octavo  volumes  of  about  1500  pages,  extra  cloth.     $7  00. 


TEHMANN  [G.   G.). 

PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edi- 
tion by  Georgb  E  Day,  M.  D.,  F.  R.  S.,  Ac,  edited  by  R.  E.  Rogers,  M.  D.,  Professor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Penn.^ylvania,  with  illustration*? 
selected  from  Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates.  Com- 
plete in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  two 
hundred  illustrations,  extra  cloth.     $6  00. 


T>T  THE  SAME  AUTHOR. 

MANUAL  OF   CHEMICAL   PHYSIOLOGY.     Translated  from  the 

German,  with  Notes  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  Introductory 
Ess.ay  on  Vital  Force,  by  Professor  Samuel  Jackson,  M.  D.,  of  the  University  of  Penn.syl- 
vania.  With  illustrations  on  wood.  Ie  one  very  handsome  octavo  volume  of  336  pageg, 
estra  cloth.     $2  25. 


10 


Henry  C.  Lea's  Publications — (Chemistry). 


ATTFIELD  (JOHN),  Ph.D., 

Pro/es-t'ir  of  Prnnticnl  Chemistry  to  the.  Phnrmnceutieal  Society  of  Great  Britain,  A-e. 

.  CHEMISTRY,    GENERAL,  MEDICAL,  AND  PHARMACEUTICAL; 

inchuline:  the  Chemistry  of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.  Fiflh  Edition,  revised 
by  the  author.     In  one  handsome  royal  12mo.  volume 

We  commend  the  work  heartily  as  one  of  the  hest 
text-books  extant  for  the  medical  student. — Detroit 
Sev.  of  Med.  aiui  Pharm.,  Feb.  1S72. 

The  best  work  of  the  kind  in  the  English  language. 
—N.  Y.  Psychologicol  Journal,  Jan.  1872. 

The  work  is  constructed  with  direct  reference  to 
the  wants  of  medical  and  pharmaceutical  students; 
and,  although  an  English  work,  the  points  of  differ- 
ence between  the  Bi-itish  and  United  States  Pharma- 
copoeias are  indicated,  making  it  as  useful  here  as  in 
England.  Altogether,  the  book  is  one  we  can  heart- 
ily recommend  to  practitioners  as  well  as  students. 
— i\'.  Y.  Med.  Journal,  Dec.  1S71. 

It  differs  from  other  text-books  in  the  following 
particulars:  first,  in  the  exclusion  of  matter  relating 
to  compounds  which,  at  present,  are  only  of  interest 
to  the  scientific  chemist ;  secondly,  in  containing  the 
ch'emistry  of  every  substance  recognized  offlcially  or 
in  general,  as  a  remedial  agent.  It  will  be  found  a 
roost  valuable  book  for  pupils,  assistants,  and  others 
engaged  in  medicine  and  pharmacy,  and  we  heartily 
commend  it  to  our  readers. — Canada  Lancet,  Oct. 
1871. 

When  the  original  English  edition  of  this  work  was 
published,  we  had  occasion  to  express  our  high  ap- 
preciation of  its  worth,  and  also  to  review,  in  con- 
siderable detail,  the  main  features  of  the  book.  As 
the  arrangement  of  subjects,  and  the  main  part  of 
the  text  of  tiie  present  edition  are  similar  to  the  for- 
mer publication,  it  will  be  needless  for  us  to  go  over 
the  gronud  a  second  time  ;  we  may,  however,  call  at- 
tention to  a  marked  advantage  possessed  by  the  Ame- 


{Neariy  Readij.) 

rican   work— we  allude   to  the  introduction  of  the 

chemistry  of  the  preparations  of  the  United  States 
Pharmacopoeia  as  well  as  that  relating  to  the  British 
authority.  —  Canadian  Pharmaceutical  Journal, 
Nov.  1S71. 

Chemistry  has  borne  the  name  of  being  ahard  sub- 
ject to  master  by  the  student  of  medicine,  and 
chiefly  because  so  much  of  it  consists  of  compounds 
only  of  interest  to  the  scientific  chemist ;  in  this  work 
such  portions  are  modified  or  altogether  left  out,  and 
in  the  arrangement  of  the  subject  matter  of  the  work, 
practical  utility  is  sought  after,  and  we  think  fully 
attained  We  commend  it  for  its  clearness  and  order 
to  both  teacher  and  pupil. — Oregon  3Ied.  and  Surg. 
Reporter,  Oct.  1S71. 

It  contains  a  most  admirable  digest  of  what  is  spe- 
cially needed  by  the  medical  student  in  all  that  re- 
lates to  practical  chemistry,  and  consitntes  for  him 

a  sound  and  useful  text-book  on  the  subject 

We  commend  it  to  the  notice  of  »very  medical,  as  well 
as  pharmaceutical,  student.  We  only  regret  that  we 
had  not  the  book  to  depend  upon  in  working  up  the 
subject  of  practical  and  pharmaceutical  chemistry  for 
the  University  of  London,  for  which  it  seerns  to  ua 
that  it  is  exactly  adapted.  This  is  paying  the  book  a 
high  compliment. — T^ie  Lancet. 

Dr.  Attfield's  book  is  written  in  a  clear  and  able 
manner;  it  is  a  work  siu  generis  and  without  a  rival  ; 
it  will  be  welcomed,  we  think,  by  every  reader  of  the 
'Pharmacopoeia,'  and  is  quite  as  well  suited  for  the 
medical  student  as  for  the  pharmacist. — The  Chemi- 
cal News. 


w 


VHLER  AND  FITTIG. 
OUTLINES  OP  ORGANIC  CHEMISTRY 


Translaterl  with  Ad- 


ditions from  the  Eighth  German  Edition.     By  Ira  Eemsex.  M.D.,  Ph.D.,  Profe.ssor  of 

Chemistry  and  Physics  in  Williams  College,  Mass.     In  one  handsome  volume,  royal  12mo. 

of  550  pp.  extra  cloth,  ,$.3.      {Just  Ready.) 

As  the  numerous  editions  of  the  original  attest,  this  worl?  is  the  leading  text-hook  and  standard 

authority  throughout  Germany  on  its  important  and  intricate  subject — a  position  won  for  it  by 

the  clearness  and  conciseness  which  are  its  distinguishing  characteristics.     The  translation  has 

been  executed  with   the  approbation  of  Profs.  Wbhler  and  Fittig,  and  numerous  additions  and 

alterations  have  been  introduced,  so  as  to  render  it  in  every  respect  on  a  level  with  the  most 

advanced  condition  of  the  science. 


0 


DUNG  [WILLIAM), 

Lectiirer  on  Chemistry  at  St.  Bartholomew's  ffospitjl,  Ac. 

A  COURSE  OF  PRACTICAL  CHEMISTRY,  arranged  for  the  Use 

of  Medical  Students.    With  Illustrations.    From  the  Fourth  and  Revised  London  Edition. 
In  one  neat  royal  12mo.  volume,  extra  cloth.     $2.      {Lately  Issued.) 


Asa  work  for  the  practitioner  it  cannot  be  excelled. 
It  is  written  plainly  and  concisely,  and  gives  in  a  very 
small  compass  the  information  required  by  the  busy 
practitioner.  '  It  is  essentially  a  work  for  the  physi- 
cian, and  no  one  who  purchases  it  will  ever  regret  the 
outlay.  In  addition  to  all  that  is  usually  given  in 
connection  with  inorganic  chemistry,  there  are  most 
valuable  contributions  to  toxicology,  animal  and  or- 


ganic chemistry,  etc.  The  portions  devoted  to  a  dis- 
cussion of  these  subjects  are  very  excellent.  In  no 
work  can  the  physician  find  more  that  is  valuable 
and  reliable  in  regard  to  urine,  bile,  milk,  bone,  uri- 
nary calculi,  tissue  composition,  etc.  The  work  is 
small,  rea.'-onable  in  i)rice,  and  well  published. — 
Richmond  and  Louisville  Med.  Journal,  Dec.  1869. 


flALLOWAY  [ROBERT),  F.C.S., 

\jr  Prof,  of  Applied  Cliemistry  in  the  Royal  College  of  Science  for  Ireland,  &c. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.     From  the  Fifth  Lon- 

don  Edition.    In  one  neat  royal  12iuo.  volume,  with  illustrations  ;  extra  cloth,  $2  60.     {Just 

Issued.) 
The  success  which  has  carried  this  work  through  repeated  editions  in  England,  and  its  adoption 
as  a  text-book  in  several  of  the  leading  institutions  in  this  country,  show  that  the  author  has  suc- 
ceeded in  the  endeavor  to  produce  a  sound  practical  manual  and  book  of  reference  for  the  che- 
mical student. 


Prof  Galloway's  books  are  deservedly  in  high 
esteem,  and  this  American  reprint  of  the  fifth  edition 
(1869)  of  his  Manual  of  Qualitative  Analysis,  will  be 
acceptable  to  many  American  students  to  whom  the 
Enclish  edition  is  not  accessible. — Am..  Jour,  of  Sci- 
ence and  Arts,  Sept.  1872. 


We  regard  this  volume  as  a  valuable  addition  to 
the  chemical  text-books,  and  as  particularly  calcu- 
lated to  instruct  the  student  in  analytical  researches 
of  the  inorganic  compounds,  the  importaut  vegetable 
acids,  and  of  compounds  and  various  .'■ecretious  and 
excretions  of  animal  origin. — Am.  Journ.  of  Phiirtn., 
Sept.  1872. 


Henry  C.  Lea's  Publications — (Ghemistry,  Pharmacy, Sc).       11 


nHAMDLER  {CHARLES  F.).      and     fillANDLER  [WILLIAM  H.), 

vy  Prdf.ofdhtmislrijiiitheN.  Y.  Cull,  of  vy  Prof  of  Ulimaiistry  in  the,  Lnhtyk 

riiiirinticij.  UnivernUy. 

THE    AM^:HrOA^^    chemist :    A  Monthly  Journal  of  Theoretical, 

Analyticiil,  and  Technical   Chemistry.     Each  number  aveniging  forty  large  double  col- 
umned pages  of  reading  matter.    Price  $5  per  annum  in  advance.    Single  numbers,  50  cts. 

CC?"  Specimen  numbers  to  parties  proposing  to  subscribe  will  be  sent  to  any  address  on  receipt 
of  25  cents. 

*^*  Subscriptions  can  begin  with  any  number. 

The  ra|)id  growth  of  the  Science  of  Chemistry  anil  its  infinite  applications  to  other  sciences 
and  iirts  render  a  journal  speinally  devoted  to  the  subject  a  necessity  to  those  whose  pursuits 
reijuire  familiarity  with  the  details  of  the  science.  It  has  been  the  aim  of  the  conductors  of  "The 
Amkbucan  Chemist"  to  supply  this  want  in  its  broadest  sense,  and  the  reputation  which  the 
])eriodical  has  alreacly  attained  is  a  sufficient  evidence  of  the  zeal  and  ability  with  which  they 
have  discharged  their  task. 

Assisted  by  an  able  body  of  collaborators,  their  aim  is  to  present,  within  a  moderate  compass, 
an  abstract  of  the  progress  of  the  science  in  all  its  departments,  scientific  and  technical.  Import- 
ant original  communications  and  selected  papers  are  given  in  full,  and  the  standing  of  the  "  Chem- 
ist" is  such  as  to  secure  the  contributions  of  leadini;  men  in  all  portions  of  the  country.  Besides 
this,  over  one  hundred  journals  and  transactions  of  learned  societies  in  America.,  Great  Britain, 
France,  Belgium,  Italy,  Russia,  and  Germany  are  carefully  scrutinized,  and  whatever  they  offer 
of  interest  is  condensed  and  presented  to  the  reader.  In  this  work,  which  forms  a  special  feature 
of  the  "Chemist,"  the  editors  have  the  assistance  of  M.  Alsberg,  Ph.D.,  Prof.  G.  F.  Barker,  T. 
M.  Blossom,  E.iM.,  H.  C.  Bolton,  Ph.D.,  Prof.  T.  Egleston,  E.M  ,  H.  Endemann,  Ph.D.,  Prof.  C. 
A.  Goe.ssmnnn,  Ph.D.,S.  A.  Goldschmidt,  A.M.,  E.M.,  E.  J.  Hallock.  Prof.  C.  A.  Joy,  Ph.D., 
J.  P.  Kimball,  Ph.D.,  0.  G.  Mason,  H.  Newton,  E.M.,  Prof.  Frederick  Prime,  Jr.,  Prof.  Paul 
Schweitzer,  Ph.D.,  Waldron  Shapleigh,  Rorayn  Hitchcock,  and  Elwyn  Waller,  E.M.  From  the 
thoroughness  and  completeness  with  which  this  department  is  conducted,  it  is  believed  that  no 
periodical  in  either  hemisphere  more  faithfully  reflects  the  progress  of  the  science,  or  presents  a 
larger  or  more  carefully  garnered  store  of  information  to  its  readers. 


F' 


VWNES  (GEORGE),  Ph.D. 

A  MANUAL  OF  ELEMENTARY  CHEMISTRY;   Theoretical  and 

Practical.  With  one  hundred  and  ninety-seven  illustrations.  A  new  American,  from  the 
tenth  and  revised  London  edition.  Edited  by  Robert  Bridges,  M.  D.  In  one  large 
royal  I2mo.  volume,  of  about  850  pp.,  extra  cloth,  $2  75  ;  leather,  $3  25.    {Lately  Issued.) 


This  work  is  so  well  known  tliat  it  seems  almost 
superfluous  for  us  to  speak  about  it.  It  has  been  a 
favorite  text-book  with  medical  students  for  years, 
and  its  popularity  has  iu  no  respect  diminislied. 
Whenever  we  have  been  consulted  by  medical  stu- 
dents, as  has  frequently  occurred,  what  treatise  on 
chemistry  they  should  procure,  we  have  always  re- 
commended Fownes',  for  we  regarded  it  as  the  best. 
There  is  no  work  that  combines  so  many  excellen- 
ces. It  is  of  convenient  size,  not  prolix,  of  plain 
perspicnous  diction,  contains  all  the  most  recent 
discoveries,  and  is  of  moderate  price. — Cincinnati 
Med.  Sepeiiory,  Aug.  1869. 

Large  additions  have  been  made,  especially  in  the 
department  of  organic  chemistry,  and  we  know  of  no 
other  work  that  has  greater  claims  on  the  physician, 
pharmaceutist,  or  student,  than  this.  We  cheerfully 
recommend  it  as  the  best  text-book  on  elementary 
chemistry,  and  bespeak  for  it  the  careful  attention 
of  students  of  pharmacy.— CTucaao  Pharmacist,  Aug. 
1869.  J  y  >       6 

The  American  reprint  of  the  tenth  revised  and  cor- 
rected English  edition  is  now  issued,  and  represents 
the  present  condition  of  the  science.  No  comments 
are  necessary  to  insure  it  a  favorable  reception  at 
the  hands  of  practitioners  and  students.  —  Boston 
Med.  and  Surg.  Journal,  Aug.  12,  lSd9. 

Here  is  a  new  edition  which  has  been  long  watched 
for  by  eager  teachers  of  chemistry.     In  its  new  garb, 


and  under  the  editorship  of  Mr.  Watts,  it  has  resumed 
its  old  place  as  the  most  successful  of  text-books. — 
Indian  Medical  Gazette,  Jan.  1,  1S69. 

It  will  continue,  as  heretofore,  to  hold  the  first  rank 
IS  a  text-book  for  students  of  medicine. — Chicago 
Med.  Examiner,  Aug.  1809. 

Thiswork,  long  the  recognized  Manual  of  Chemistry, 
appears  as  a  tenth  edition,  under  the  able  editorship 
■)f  Bence  Jones  and  Henry  Watts.  The  chapter  on 
the  General  Principles  of  Chemical  Philosophy,  and 
the  greater  part  of  the  organic  cliemi.'stry,  have  been 
jewritten,  and  the  whole  work  revised  iu  accordance 
with  the  recent  advances  in  chemical  knowledge.  It 
remains  the  standard  text-book  of  chemistry. — Dub- 
lin Quarterly  Journal,  Feb.  1S69. 

There  is  probably  not  a  student  of  chemistry  in  this 
country  to  whom  the  admirHble  manual  of  the  late 
Professor  Fownes  is  unknown.  It  has  achieved  a 
success  which  we  believe  is  entirely  without  a  paral- 
lel among  scientific  text-books  in  our  language.  This 
success  has  arisen  from  the  fact  that  there  is  no  En- 
glish work  on  chemistry  which  combines  so  many 
excellences.  Of  convenient  size,  of  attractive  form, 
clear  and  concise  in  diction,  well  illustrated,  and  of 
moderate  price,  it  would  seem  that  every  rc'iuisite 
for  a  student's  haud-book  has  been  attained. — The 
Chemical  Ntws,  Feb.  1S69. 


^0  WMAN  [JOHN  E.) ,  31.  D. 

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.    Edited 

by  C.   L.  Bloxam,   Professor  of  Practical  Chemistry  in  King's  College,  London.       Fifth 
American,  from  the  fourth  and  revised  English  Edition.     In  one  neat  volume,  royal  12mo., 
pp.  351,  with  numerous  illustrations,  extra  cloth.     |2  25. 
J^T  THE  fiA3IE  AUTHOR.  

INTRODUCTION   TO   PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.     Fifth  American,  from  the  fifth  and  revised  London  edition.     AVith  numer- 
ous illustrations.     In  one  neat  vol.,  royal  I2mo.,  extra  cloth.     $2  25. 


KNAPP'S  TECHNOLOGY  ;  or  Chemistry  Applied  to 
the  Arts,  and  to  Manufactures.  With  American 
additions,  by  Prof.  Walter  R.  Johsbon.    In  two 


very  handsome  octavo  volumes,  with  £00  ■wood 
engravings,  extra  cloth,  (ii6  00. 


12       Henry  C.  Lea's  Publications — (Mat.  Med.  and  Therapeutics). 


pARRISH  [EDWARD], 

■'-  Proftsfior  of  MrUeria  Medica  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.     Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.     With  many  Formulae  and 
Prescriptions.     Third  Edition,  greatly  improved.     In  one  handsome  octavo  volume,  of  850 
pages,  with  several  hundred  illustrations,  extra  cloth.     $5  00;  leather,  $6  00. 
The  immense  amount  of  practical  information  condensed  in  this  volume  may  be  estimated  from 
the  fact  that  the  Index  contains  about  4700  items.      Under  the  head  of  Acids  there  are  312  refer- 
ences ;  under  Emplastrum,  36  ;  Extracts,  159;  Lozenges,  25;  Mixtures,  55;  Pills,  56  ;  Syrups, 
Tinctures,  138;  Unguentum,  57,  &c. 


131 

We  have  examined  this  large  volume  with  a  good 
d'?al  of  care,  and  find  that  the  author  has  completely 
exhausted  the  subject  npou  which  he  treats  ;  a  more 
complete  work,  we  thinli,  it  would  be  impossible  to 
find.  To  the  student  of  pharmacy  the  work  is  indis- 
pensable ;  indeed,  so  far  as  we  know,  it  is  the  only  one 
of  its  kind  in  existence,  and  even  to  the  physician  or 
medical  student  who  can  spare  five  dollars  to  pur- 
chase it,  we  feel  sure  the  practical  information  he' 
will  obtain  will  more  than  compensate  him  for  the 
outlay. — Canada  Med.  Journal,  Nov.  1S64. 

The  medical  student  and  the  practising  physician 
will  find  the  volume  of  inestimable  worth  for  study 
and  reference. — San  Francisco  Med.  Press,  July, 
1S64. 

When  we  say  that  this  book  is  in  some  respects 
the  best  which  has  been  published  on  the  subject  in 
the  English  language  for  a  great  many  years,  we  do 


not  wish  it  to  be  understood  as  very  extravagant 
praise.  In  truth,  it  is  not  so  much  the  best  as  tha 
jnly  book. —  !ZVie  London  Chemical  News. 

An  attempt  to  furnish  anythitg  like  an  analysis  ol 
Parrish"s  very  valuable  and  elaborate  Treatise  on 
Practical  Pharmacy  would  require  more  space  than 
ve  have  at  our  disposal.  This,  however,  is  not  so 
much  a  matter  of  regret,  inasmuch  as  it  would  he 
difficult  to  think  of  any  point,  however  minute  and 
apparently  trivial,  connected  with  the  manipulation 
if  pharmaceutic  substances  or  appliances  which  has 
not  been  clearly  and  carefully  discussed  in  this  vol- 
ume. Want  of  space  prevents  our  enlarging  further 
on  this  valuable  work,  and  we  must  conclude  by  a 
simple  expression  of  our  hearty  appreciation  of  it» 
merits. — DtMiii  Qiiarterly  Jour,  of  Medical  Science, 
August,  1S64. 


OTILLE  {ALFRED),  M.D., 

^  Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History 
Fourth  edition,  revised  and  enlarged.    In  two  large  and  handsome  octavo  volumes.     {Pre- 
paring.) 


Dr.  Salle's  .>plendid  work  on  therapeutics  and  ma- 
teria medica. — London  Med.  Times,  April  8,  1865. 

Dr.  Still6  stands  today  one  of  the  best  and  most 
honored  representatives  at  home  and  abroad,  of  Ame- 
rican medicine ;  and  these  volumes,  a  library  in  them- 
selves, a  treasuje-house  for  every  studious  physician, 
assure  his  fame  even  had  he  done  nothing  more. — The 
Western  Journal  of  Medicine,  Dec.  18B8. 

We  regard  this  work  as  the  best  one  on  Materia 
Medica  in  tlie  English  language,  and  as  such  it  de- 
serves the  favor  it  has  received. — Am.  Journ.  Medi- 
cal Sciences,  July  1S6S. 

We  need  not  dwell  on  the  merits  of  the  third  edition 
of  this  magnificently  conceived  work.  It  is  the  work 
on  Materia  Medica,  in  which  Therapeutics  are  prima- 
rily considered — the  mere  natural  history  of  drugs 
being  briefly  disposed  of.  To  medical  practitioners 
this  is  a  very  valuable  conception.  It  is  wonderful 
how  much  of  the  riches  of  the  literature  of  Materia 
Medica  has  been  condensed  into  this  book.  The  refer- 
ences alone  would  make  it  worth  possessing.  But  it 
is  not  a  mere  compilation.  The  writer  exercises  a 
good  judgment  of  his  own  on  the  great  doctrines  and 
points  of  Therapeutics.  For  purposes  of  practice, 
Still6's  book  is  almost  unique  as  a  repertory  of  in- 
formation, empirical  and  scientific,  on  the  actions  and 
uses  of  medicines. — London  Lancet,  Oct.  31,  1868. 

Through  the  former  editions,  the  professional  world 
l8  well  acquainted  with  this  work.     At  home  and 


abroad  its  reputation  as  a  standard  treatise  on  Materia 
Medica  is  securely  established.  It  is  second  to  no 
work  on  the  subject  in  the  English  tongue,  and,  in- 
deed, is  decidedly  superior,  in  some  respects,  to  any 
other. — Pacific  Med.  and  Surg  Journal,  July,  1868. 
Stilld's  Therapeutics  is  incomparably  the  best  work 
on  the  subject.— iV.  T.  Med.  Gazette,  Sept.  26,  1868. 

Dr  Still6's  work  is  becoming  the  best  known  of  any 
of  our  treatises  on  Materia  Medica.  .  .  .  One  of  the 
most  valuable  works  in  the  language  on  the  subject* 
of  which  it  treats. — N.  Y.  Med.  Journal,  Oct.  186S. 

The  rapid  exhaustion  of  two  editions  of  Prof.  Still6» 
scholarly  work,  and  the  consequent  necessity  for  a 
third  edition,  is  BUtticient  evidence  of  the  high  esti- 
mate placed  upon  it  by  the  profession.  It  is  no  exag- 
geration to  say  that  there  is  no  superior  work  upon 
the  subject  in  the  English  language.  The  present 
edition  is  fully  up  to  the  most  recent  advance  in  the 
science  and  art  of  therapeutics. — Leavenworth  Medi- 
cal Herald,  Aug.  1S68. 

The  work  of  Prof.  Still6  has  rapidly  taken  a  high 
place  in  professional  esteem,  and  to  say  that  a  third 
edition  is  demanded  and  now  appears  before  us,  suffi- 
ciently attests  the  firm  position  this  treatise  has  made 
for  itself.  As  a  work  of  great  research,  and  scholar- 
ship, it  is  sale  to  say  we  have  nothing  superior.  It  is 
exceedingly  full,  and  the  busy  practitioner  will  find 
ample  suggestions  upon  almost  every  important  point 
of  therapeutics. — Cincinnati  Lancet,  Aug.  1S68. 


o 


RIFFITH  [ROBERT  E.),  M.D. 

A  TJNIYERSAL  FORMULARY,   Containing  the  Methods  of  Pre- 
paring and  Administering  Oflncinal  and  other  Medicines.     The  whole  adapted  to  Physiciana 
and  Pharmaceutists.     Second  edition,   thoroughly  revised,  with  numerous  additions,  by 
Robert  P.  Thomas,  M.D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of 
Pharmacy.     In  one  large  and   handsome   octavo  volume  of  650  pages,  double-columns. 
Extra  cloth,  $4  00;  leather,  $5  00. 
Three  complete  and  extended  Indexes  render  the  work  especially  adapted  for  immediate  consul- 
tation.    One,  of  Diseases  and  their  Remedies,  presents  under  the  head  of  each  disease  the 
remedial  agents  which  have  been  usefully  exhibited  in  it,  with  reference  to  the  formuljB  containing 
them — while  another  of  Pharmaceutical  and  Botanical  Names,  and  a  very  thorough  General 
Index  afford  the  means  of  obtaining  at  once  any  information  desired.     The  Formulary  itself  ia 
arranged  alphabetically,  under  the  heads  of  the  leading  constituents  of  the  prescriptions. 
We  know  of  none  in  our  language,  or  any  other,  so  comprehensive  in  its  details. — London  Lancet. 
One  of  the  most  complete  works  of  the  kind  in  any  language. — Edinburgh  Med.  Journal. 
We  are  not  cognizant  of  the  existence  of  a  parallel  work. — London  Med.  Oaietle. 


Henry  C.  Lea's  Publications — {Mai.  Med  and  Titer apeutics).       13 


pEREIRA  [JONA  THAN),  M.  /).,  F.  R.S.  and  L.S. 

MATERIA    MEDICA    AND  THERAPEUTICS;    being  an  Abridii- 

ment  of  the  late  Dr.  Pcreira's  Elements  of  Materia  Medica,  arranged  in  conformity  with 
the  British  Phiirmacopocia,  and  adiipted  to  the  use  of  Medical  Pracjtitioners,  Cheinista  and 
Drufrj^ists,  Medical  and  Phnrinaceiitical  Students,  Ac.  By  F.  J.  Faiike,  M.D.,  Senior 
Physician  to  St.  Bartliolotnevv's  Hosjiital,  and  London  Editor  of  the  British  Pharniacopceia  ; 
assisted  by  Robert  Bentley,  M.R.C.S.,  Professor  of  Materia  Medica  and  Botany  to  the 
Pharmaceutical  Society  of  (ireat  Britain;  and  by  Robert  VVarington,  F.R.S.,  Chemical 
Operator  to  the  Society  of  Apotheonries.  With  numerous  additions  and  references  to  the 
United  States  Pharmacopoeia,  by  Horatio  C.  Wood,  M.D.,  Professor  of  Botany  in  the 
University  of  Pennsylvania.  In  one  large  and  handsome  octavo  volume  of  1(140  tdosely 
printed  pages,  with  2;^6  illustrations,  extra  cloth,  $7  00;    leather,   raised  bands,  $8  00 


The  ta.sk  of  tlie  .\iuerican  editor  has  evideutly  been 
no  winecui'e,  for  not  ouly  hiis  he  giv(ui  to  us  all  tliat 
Is  coutrtiiied  in  the  ahritlgmeut  useful  for  our  piir- 
pose.s,  but  by  a  careful  and  judicious  embodiuient  of 
over  a  hundred  new  remedies  has  increased  the  size 
of  the  former  work  fully  one-third,  besides  adding 
many  new  illustrations,  some  of  which  are  original. 
We  unhesitatingly  say  that  by  so  doing  he  has  pro- 
portionately increased  tlio  value,  not  only  of  the  con- 
densed edition,  hut  has  extended  the  applicahility  of 
the  great  original,  and  lias  placed  his  medical  coun- 
trymen under  lasting  obligations  to  him.  The  Ame- 
rican physician  now  nas  all  that  is  needed  in  the 
shape  of  a  complete  treatise  on  materia  medica,  and 
the  mediqal  student  has  a  text-book  which,  for  prac- 
tical utility  and  intrinsic  worth,  stands  unparalleled. 
Although  of  considerable  size,  it  is  none  too  large  for 
the  purposes  for  which  it  has  been  intended,  and  every 
medical  man  should,  in  justice  to  himself,  spare  a 
place  for  it  upon  his  book-shelf,  resting  assured  that 
the  more  he  consults  it  the  better  he  will  be  satisfied 
of  its  excellence. — N.  Y.  Mc/l.  Record,  Nov.  15,  1866. 

It  will  fill  a  place  which  no  other  work  can  occupy 
lu  the  library  of  the  physician,  student,  and  apothe- 
eary. — Boston  Med.  and  Surff.  Journal,  Nov.  8,  1866. 

Of  the  many  works  on  Materia  Medica  which  have 
appeared  since  the  issaing  of  the  British  Pharmaco- 


poeia, none  will  be  more  acceptable  to  the  student 
and  practitioner  than  the  presoul.  Pereira's  Materia 
Medica  had  long  ago  asserted  for  itself  the  position  of 
being  tlie  most  complete  work  on  the  subject  in  the- 
English  language.  But  its  vary  completeness  stood 
in  the  way  of  its  success.  Except  in  the  way  of  refer- 
ence, or  to  those  who  made  a  special  study  of  Materia 
Medica,  Dr.  Pereira's  work  was  too  full,  and  its  pe- 
rusal required  an  amount  of  time  which  few  had  at 
their  disposal.  Dr  Farre  has  very  j  udiciously  availfd 
himself  of  the  opportunitv  of  the  publication  of  the 
new  Pharmacopoeia,  Dybrindngout  an  abridged  edi- 
tion of  the  great  work.  This  edition  of  Pereira  is  by 
no  means  a  mere  abridged  re-issue,  but  contains  many 
improvements,  both  in  the  descriptive  and  thera- 
peutical departments.  We  can  recommend  it  as  a 
very  excellent  and  reliable  text-book. — Edinburgh 
Med.  Journal,  February,  1S66. 

The  reader  cannot  fail  to  be  impressed,  at  a  glance, 
with  the  exceeding  value  of  this  work  as  a  cornpend 
of  nearly  all  useful  knowledge  on  the  materia  medica. 
We  are  greatly  indebted  to  Professor  Wood  for  his 
adaptation  of  it  to  our  meridian.  Without  his  emen- 
dations and  additions  it  would  lose  much  of  its  value 
to  the  American  student.  With  them  it  is  an  Ameri- 
can book..—  Po.cijio  Medical  and  Surgical  Journal, 
December,  1866. 


fjLLIS  [BENJAMIN),  M.D. 

THE  MEDICAL  FORMULARY:  being  a  Collection  of  Pvescripiions 

derived  from  the  writings  and  practice  of  mnny  of  the  most  eminent  physicians  of  America 
and  Europe.    Together  with  the  usual  Dietetic  Preparation.?  and  Antidotes  for  Poisons.    The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Observations.    Twelfth  edi- 
tion, carefully  revised  and  much  improved  by  Albert  H.  Smith,  M.  D.    In  one  volume  Sv- . 
of  376  pages,  extra  cloth,  $3  00.      (Lately  Published.) 
This  work  has  remained  for  some  time  out  of  print,  owing  to  the  anxious  care  with  which  the 
Editor  has  sought  to  render  the  present  edition  worthy  a  continuance  of  the  very  remarkable 
favor  which  has  carried  the  volume  to  the  unusual  honor  of  a  Twelfth  Edition.     He  has  sedu- 
lously endeavored  to  introduce  in  it  al!  new  preparations  and  conibinntions  deserving  of  confidence, 
besides  adding  two  new  classes,  Antemeties  and  Disinfectants,  with  brief  references  to  the  inhalation 
of  atomized  fluids,  the  nasal  douche  of  Thudichum,  suggestions  upon  the  method  of  hypodermic 
injection,  the  administration  of  anaesthetics,  <fec.  &c.     To  accommodate  these  numerous  additions, 
he  has  omitted  much  which  the  advance  of  science  has  rendered  obsolete  or  of  minor  import^tnce, 
notwithstanding  which  the  volume  has  been  increased  by  more  than  thirty  p.iges.      A  new' feature 
will  be  found  in  a  copious  Index  of  Diseases  and  their  remedies,  which  cannot  but  increase  the 
value  of  the  work  as  a  suggestive  book  of  reference  for  the  working  practitioner.    Every  precaution 
has  been  taken  to  secure  the  typographical  accuracy  so  necessary  in  a  work  of  this  nature,  and  it 
iH  hoped  that  the  new  edition  will  fully  maintain  the  position  which  "  Ellis'  Formulary''  has 
long  occupied. 


c 


JARSON  {JOSEPH],  M.D., 

Professor  of  Materia  Med.tca  and  Pharmacy  in  the  Uniiier.iify  of  Penn.'iylvania,  &c. 

SYNOPSIS  OF  THE   COURSE   OF   LECTURES   ON   MATERIA 

MEDICA  AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.  With  three 
Lectures  on  the  Modus  Operandi  of  Medicines.  Fourth  and  revised  edition,  estra  cloth, 
$3  00. 


CCXGLISON'S  NEW  REMEDIES,  WITH  FORMUL.^ 
FOR  THEIR  PREPARATIO.N  AND  ADMINISTRA- 
TION Seventh  edition,  with  extensive  additions. 
One  vol.  Svo.,  pp.  770;  extra  cloth,     ijii  00. 

KOriiE'S  MATERIA  MEDICA  AND  THERAPEU- 
TICS. Edited  by  Joseph  Carson,  M.  D.  With 
ninety-eight  illustrations.  1  vol.  8vo.,  pi>.  700,  ex- 
tra cloth.     $3  00. 

OHRISTISON'S  DISPENSATORY.  With  copious  ad- 
dUioas,  and  213  large  wood-engraviugB.     By  G 


Eqlespei.d  Grtppith,  M.  D.   One  vol.  Svo.,  pp.  1000 ; 
extra  cloth.     $4  no. 

CARPENTER'S  PRIZE  ESSAT  ON  THE  USE  OF 
Alcoholic  Liquors  in  Health  and  Disease.  New 
edition,  with  a  Preface  by  D.  F.  Condie,  M.D.,  and 
explanations  of  scientific  words.  In  one  neat  )2mo. 
volume,  pp.  17S,  extra  cloth.     60  cents. 

De  JONGH  on  the  THREE  KINDS  OF  COD-LIVEB 
Oil,  with  their  Chemical  and  Therapeutic  Pro- 
perties    1  vol.  12mo.,  cloth.    75  cents. 


14  Henry  C.  Lea's  Pl'blications — {Pathology^  <&c.) 

riREEN  ( T.  HENR  Y) ,  M.  D., 

Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-Cross  Hospital  Medical  School. 

PATHOLOGY  AND  MORBID  ANATOMY.     With  numerous  Hlus- 

trations  on  Wood.     In  one  very  handsome  octavo  volume  of  over  250  pages,  extra  cloth, 

§2  50.     {Lately  Published  ) 

The  scope  and  object  of  this  volume  can  be  gathered  from  the  following  condensed 

We  have  been  very  much  pleased  by  oar  perusal  of    thology  and  morbid  anatomy.  The  author  shoirs  that 

this  little  volume.    It  is  the  ouly  one  of  the  kind  with     he  has  been  not  only  a  student  of  the  teachings  of  his 

which  we  are  acquainted,  and  practitioners  as  well     confreres  in  this  branch  of  science,  but  a  practical 

as  students  will  find  it  a  very  useful  guide  ;  for  the     and  conscientious  laborer  in  the  post-mortem  cham- 

iuformalion  is  up  to  the  day,  well  and  compactly  ar-     ber.     The  work  will  prove  a  useful  one  to  the  great 

vauged,  without  being  at  all  scanty. — London  Lan-  '  mass  of  students  and  practitioners  whose  time  for  de- 

cet,  Oct.  7,  1871.  votion  to  this  class  of  studies  is  limited. — Am.  Joiirn. 

It  embodies  in  a  comparatively  small  space  a  clear  i  of  Sijphilography,  April,  1S72. 
statement  of  the  present  state  of  our  knowledge  of  pa-  1 


GLUGE'S  ATLAS  OF  PATHOLOGICAL  HISTOLOGY. 
Translated,  with  Notes  and  Additions,  by  Joseph 
Leidt,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  320  copper-plate  figures,  plain  and 
colored,  extra  cloth.     $4  00. 


tical  Relations.   In  two  large  and  handsome  octavo 
volumes  of  nearly  1.500  pages,  extra  cloth.     $7  00. 

HOLLAND'S     MEDICAL    NOTES    ANI     KEFLEC- 
TiONS.     1  vol.  Svo.,  pp.  500,  extra  cloth.     $3  .50. 


SI.MON'S  GENERAL  PATHOLOGY,  as  conducive  t<  i  WH.\TTOOBSERYEATTHE  BEDSIDE  AND  AFTER 

the  Establishment  of  Rational   Principles  for  th»  |  Death  in  llEDic.iL  Cases.     Published  under  the 

Prevention   and  Cure  of  Disease.     In   one  octavo  authority  of  the  London  Society  for  Medical  Obser- 

volume  of  212  pages,  extra  cloth.     $12.5.                     i  vation.     From  the  second  London  edition.     1  vo). 


SOLLY  ON  THE  HUMAN  BRAIN  ;  its  Structure,  Phy- 
siology, and  Diseases.  From  the  Second  and  much 
enlarged  London  edition.  In  one  octavo  volume  of 
JjOOpages, with  120 wood-cuts;  extra   cloth.    $2  50. 

LA  ROCHE  ON  YELLOW  FEYER,  considered  in  its 
Historical,  Pathological,  Etiological,  andTherapeu- 


royal  12mo.,  extra  cloth.     $1  00. 

LAYCOCK'S    LECTURES    ON    THE    PRINCIPLES 
.    AXD   Methods  of  Medical  Observation  and  Re- 
search.    For  the   use  of  advanced   students  and 
junior  practitioners.   In  one  very  neat  royal  12ino. 
volume,  extra  cloth.    $1  00. 


pROSS  [SAMUEL  D.),  M.  D., 

V-^  Professor  of  Surgery  in  the  .Jefferson  Medical  College  of  Philridelphia. 

ELEMENTS    OF    PATHOLOGICAL  ANATOMY.     Third    edition, 

thoroughly  revised  and  greatly  improved.  In  one  large  and  very  handsome  octavo  volume 
of  nearly  800  pages,  with  about  three  hundred  and  fifty  beautiful  illustrations,  of  which  a 
large  number  are  from  original  drawings  ;   extra  cloth.     $4  00. 


TONES  [G.  HANDFIELD).  F.R.S.,  and  SIEVEKINO  [ED.  H.),  M.D., 

*J  Assistant  Physicians  and  Lecturers  iti  St.  Mary's  Hospital. 


Physicians  and  Lecturers  :"?i  St.  Mary's  Hospital. 

A  MANUAL  OF   PATHOLOGICAL  ANATOMY.     First  American 

edition,  revised.     With  three  hundred  and  ninety-seven  handsome  wood  engravings.     In 
one  large  and  beautifully  printed  octavo  volume  of  nearly  750  pages,  extra  cloth,  $3  50. 


B 


ARCLAT  [A.  W.),  31,  D. 

A  MANUAL  OF  MEDICAL  DIAGNOSIS;  being  an  Analysis  of  the 

Signs  and  Symptoms  of  Disease.     Third  American  from  the  second  and  revised  London 
edition.     In  one  neat  octavo  volume  of  451  pages,  extra  cloth.     $3  50. 


lyiLLIAMS  [CHARLES  J.  B.),  M.D., 

'  '  Professor  of  Clinical  Medicine  in  University  College,  London. 

PRINCIPLES  OF  MEDICINE.     An  Elementary  View  of  the  Causes, 

Nature,  Treatment,  Diagnosis,  and  Prognosis  of  Disease;  with  brief  remarks  on  Hygienics, 
or  the  preservation  of  health.  A  new  American,  from  the  third  and  revised  London  edition, 
In  one  octavo  volume  of  about  500  pages,  extra  cloth.     $.3  50. 


TyUNGLISON,  FORBES,  TWEEDIE,  AND  CONOLLY. 

THE  CYCLOPAEDIA   OF   PRACTICAL  MEDICINE:   comprising 

Treatises  on  the  Nature  and  Treatment  of  Diseases,  Materia  Medica  and  Therapeutics, 
Di.seases  of  Women  and  Children,  Medical  Jurisprudence,  &c.  Ac.  In  four  large  super-royal 
octavo  volumes,  of  3254  double-columned  pages,  strongly  and  handsomely  bound  in  leather, 
$15;  extra  cloth.     $11. 

*^*  This  work  contain?  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed 
by  sixty-eight  distinguished  physicians. 

TPOX  [  WILSON).  M. D., 

-'-  Holme  Prof,  of  Clinical  Med.,  Vniversify  Coll.,  London. 

THE  DISEASES  OF  THE  STOMACH:  Being  the  Third  Edition  of 

the  "Diagnosis  and  Trenlment  of  the  Varieties  of  Dyspepsia."     Revised  and  Enlarged. 
With  illustrations.     In  one  handsome  octavo  volume.      (In  Press.) 

The  present  edition  of  Dr.  Wilson  Fox's  very  admi-  '  Dr.  Fox  has  put  forth  a  volume  of  uncommon  ex- 
ruble  wiirk  differs  from  the  preceding  in  that  it  deals  cellence,  which  wo  feel  very  sure  will  takf  a  high 
with  other  maladies  than  dyspepsia  ouly. — London  ,  rank  among  works  that  treat  of  the  stomach. — Am. 
Med.  Times,  Feb.  S,  1873.  I  Practitioner,  March,  1S73. 


Henry  C.  Lea's  Publications — (^Practice  of  Medicine). 


15 


J^LINT  {A  USTIN),  M.  D., 

-*•  ProfiKstir  of  llu,  Princiiden  iind  Practice  of  yTnlicinf.  in  BellKVue  Me.d.  Colh-ge,  N.  T. 

A   TREATISE    OX    THE    PKIXCIPLES    AXD    PRACTICE    OF 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fourth 
edition,  revised  and  onlar^red.  In  one  large  and  closely  printed  octavo  volume  of  about  1 1  DO 
pases;  handsome  extra  cloth,  $6  00;  or  strongly  bound  in  leather,  with  raised  bands,  $7  00. 
(Nearly  Ready.) 

By  common  consent  of  the  Engli.<(h  and  American  medical  press,  this  work  has  been  assigned 
to  the  highest  position  as  a  complete  ami  comjiendious  text-book  on  the  most  advanced  condition 
of  medical  science.  At  the  very  moderate  price  at  which  it  is  offered  it  will  be  found  one  of  the 
cheapest  volumes  now  before  the  profession. 

Admirable  and  uaequalled.  —  Wtsttrn  Journal  of 
Medicine,  Nov.  1869. 

Dr.  FliQt's  work,  though  claiming  no  higher  title 
than  that  of  a  text-book,  is  really  more.  He  is  a  tiiau 
of  large  clinical  experience,  and  his  book  is  full  of 
such  masterly  descriptions  of  disease  as  can  only  be 
drawn  by  a  man  intimaiely  acquainted  with  their 
various  forms.  It  is  not  so  Ions;  since  we  had  the 
pleasure  of  reviewing  liis  first  edition,  and  we  recog- 
nize a  great  improvement,  especially  in  the  general 
part  of  the  work.  It  is  a  work  which  we  can  cordially 
recommend  to  our  I'eaders  as  fully  abreast  of  the  sci- 
ence of  the  day. — Edinburgh  Med.  Journal,  Oct.  '69. 

One  of  the  best  works  of  the  kind  for  the  practi- 
tioner, and  the  most  convenient  of  all  for  the  student. 
— Am.  Jourii.  Med.  Sciences,  Jan.  1S69. 

This  work,  which  stands  pre-eminently  as  the  ad- 
vance standard  of  medical  science  up  to  the  present 
time  in  the  pra<;tice  of  medicine,  has  for  its  author 
one  who  is  well  and  widely  known  as  one  of  the 
lewdiug  practitioners  of  this  continent.  In  tact,  it  is 
seldom  that  any  work  is  ever  issued  from  the  press 
more  deserving  of  universal  recommeadatiou. — Do- 
minion Med.  Journal,  May,  18ti9. 

The  third  edition  of  this  mostexcellont  book  scarce- 
ly needs  any  commendation  from  us.  The  volume, 
as  it  stands  now,  is  really  a  marvel:  first  of  all,  it  is 


sxcellontly  printed  and  hound — and  we  encounter 
that  luxury  of  America,  tho  ready-cut  i)ages,  which 
the  Yankees  are  'cute  enough  to  insist  upon — nor  are 
these  by  any  means  trifles  ;  but  the  contents  of  the 
book  are  astonishing.  Not  only  is  it  wonderful  that 
Anyone  man  can  h.ive  grasped  in  hismiud  thewhole 
■!Cope  of  medicine  with  that  vigor  which  Dr.  Flint 
ihows,  but  the  condensed  yet  clear  way  In  which 
this  is  done  Is  a  perfect  literary  triumph.  Dr.  Flint 
IS  pre-eminently  one  of  the  strong  men,  whose  right 
to  do  this  kind  of  thing  is  well  admitted  ;  and  we  say 
ao  more  than  the  tiuth  when  we  aflirm  that  he  is 
very  nearly  the  only  living  m;in  that  could  do  it  with 
such  results  as  the  volume  before  us. — T lie  London 
Practitioner,  March,  1869. 

This  is  in  some  respects  the  best  text-hook  of  medi- 
cine in  our  language,  and  it  is  highly  appreciated  ou 
the  other  side  of  the  Atlantic,  inasmuch  as  the  first 
edition  was  exhausted  in  a  few  months.  The  second 
sdition  was  little  more  than  a  reprint,  but  the  present 
has,  as  the  author  says,  been  thoroughly  revi.-ed. 
Much  valuable  matter  has  been  added,  and  by  ma'iC- 
ing  the  type  smaller,  the  bulk  of  the  volume  is  not 
much  increased.  The  weak  point  in  many  American 
works  is  pathology,  but  Dr.  Flint  has  taken  peculiar 
pains  on  this  point,  greatly  to  the  value  of  the  book. 
— London  Med.  Times  and  Gazette,  Feb.  6,  lSt59. 


BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  Additions'by  D.  F.  Cokdie, 
M.  D.     1  vol.  8vo.,  pp.  600,  cloth.     $2  50. 


TODD'S  CLINICAL  LECTURES  ON  CERTAIN  ACUTE 
Diseases.  In  one  neat  octavo  volume,  of  320  pages, 
extra  cloth.    $2  50. 


F 


.ArY{F.W.),M.D.,F.R.S., 

Senior  Asst.  Physician  to  and  Lecturer  on  Physiology,  at  Guy's  ffospitnl,  Ac. 

A  TREATISE  ON  THE    FUNCTION  OF   DIGESTION;  its  Disor- 
ders and  their  Treatment.     From  the  second  London  edition.     In  one  handsome  volume, 
small  octavo,  extra  cloth,  $2  00.      {Lately  Publisked.) 
The  work  before  us  is  one  which  deserves  a  wide     treatise,  and  sufficiently  exhaustive  for  all  practical 
circulation.     We  know  of  no  better  guide  to  the  study     purposes. — Leavenworth  Med.  Herald,  July,  1S69. 
of  digestion  and  its  disorders.— Sf.  Louvi  Med.  and        ^  ^^^y  valuable  work  on  the  subject  of  which  it 
Surg.  Journal,  July  10,  1SB9.  treats.    "Small,  yet  it  is  full  of  valuable  information. 

A  thoroughly  good  book,  being  a  careful  systematic    — Cincinnati  Med.  Repertory,  June,  1869. 


jDRINTON  {WILLIAM),  M.D.,  F.R.S. 
-^LECTURES  ON  THE  DISEASES  OF  THE   STOMACH;   with  an 

Introduction  on  its  Anatomy  and  Physiology.  From  the  second  and  enlarged  London  edi- 
tion. With  illustrations  on  wood.  In  one  handsome  octavo  volume  of  about  300  pages, 
extra  cloth.     $3  25. 


(CHAMBERS  {T.K.),  M.D., 

^  Gunmdting  Physician  to  St.  Mary's  Hospital,  London,  &c. 

THE  INDIGESTIONS;  or,  Diseases  of  the  Digestive  Organs  Functionally 

Treated.    Third  and  revised  Edition.    In  one  handsome  octavo  volume  of  383  pages,  extra 
cloth.     $3  00.     {Lately  Published.) 

So  very  large  a  proportion  of  the  patients  applying  1  merit,  we  know  of  no  more  desirable  acquisition  to 
to  every  general  practitioner  suffer  from  some  form  j  a  physician's  library  than  the  book  before  us.  He 
of  indigestion,  that  whatever  aids  him  in  their  man-  i  who  should  commit  its  contents  to  his  memory  would 
agement  directly  "puts  money  in  his  purse,"  and  in-  find  its  price  an  investment  of  capital  that  returned 
directly  does  mure  than  anything  else  to  advance  his  i  him  a  most  usurious  rate  of  interest. — N.  T.  Medical 
reputation  wiih  the  public.  From  this  purely  mate-  i  Gazette,  Jan.  28,  1871. 
rial  point  of  view,  setting  aside  its  higher  claims  to  | 


-nr  THE  SAME  AUTHOR.     {Lately  Published) 

RESTORATIVE  MEDICINE.  An  Harveian  Annual  Oration,  deliv- 
ered at  the  Royal  College  of  Physicians,  London,  on  June  24,  1871.  With  Two  Sequels. 
In  one  very  handsome  volume,  small  12mo.,  extra  cloth,  $1  00. 


Ifi 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


PRACTICE  OP  MEDI- 

Third  edition,  revised  and  im- 


fTARTSHORXE  {HENRY.).  M.D., 

J-J-  PrnfeiKor  of  Hygiene  in  the  vniverMty  of  Pennxylvania. 

ESSENTIALS  OF  THE   PRINCIPLES  AND 

CINE.     A  handy-book  for  Students  and  Practitioners. 

proved.     In  one  handsome  rov.'tl  ]2u30.  volume  of  487  pages,  clearly  printed  on  small  type, 

cloth,  $2  .38;  half  bound,  $2"6.3.  (Now  Heady.) 
The  very  remarkable  favor  which  has  been  bestowed  upon  thi.s  work,  as  manifested  in  the  ex-" 
hau.-:tion  of  two  large  editions  within  four  years,  shows  that  it  ha.'j  successfully  supplied  a  want 
lelt  by  both  student  and  practitioner  of  a  volume  which  at  a  moderate  price  and  in  a  convenient 
size  fhould  afford  a  clear  and  compact  view  of  the  most  modern  teachings  in  medical  practice. 
In  preparing  the  work  for  a  third  edition,  the  author  has  sought  to  maintain  its  character  by  very 
numerous  additions,  bringing  it  fully  up  to  the  science  of  the  day,  but  so  concisely  framed  that 
the  size  of  the  volume  is  increased  only  by  thirty  or  forty  pages.  The  extent  of  the  new  informa- 
tion thus  introduced  may  be  estimated  by  the  fact  that  there  have  been  two  hundred  and  sixty 
separate  additions  made  to  the  text,  containing  references  to  one  hundred  and  eighty  new  authors. 
This  little  epitome  of  medical  knowledge  has  al-  ;  mulas  are  appended,  intended  as  examples  merely, 


ready  been  noticed  by  us.  It  is  a  vade  mecum  of 
value,  including  in  a  short  space  most  of  what  is  es- 
sential in  the  science  and  practice  of  medicine.  The 
third  edition  is  well  up  to  the  present  day  in  the 
modern  methods  of  treatment,  and  in  the  use  of  newly 
discovered  drugs. — Boston  Med.  and  Surg.  Jo^lrnal, 
Oct.  If),  1871. 

Certainly  very  few  volumes  contain  so  much  pre- 
cise information  within  so  small  a  compass. — N.  Y. 
Med.  Journal,  Nov.  1S71. 

The  diseases  are  conveniently  classified;  symptoms. 
Causation,  diagnosis,  prognosis,  and  treatment  are 
CHrefuUy  considered,  the  whole  being  marked  by 
briefness,  but  clearness  of  expression.     Over  2.50  for- 


not  as  guides  for  unthinking  practitioners.  A  com- 
plete index  facilitates  the  use  of  this  little  volume,  in 
which  all  important  remedies  lately  introduced,  such 
as  chloral  hydiate  and  carbolic  acid,  have  received 
their  full  shareof  attention. — Am.  Joiirn.  of  P harm,., 
Nov.  1S71. 

It  is  an  epitome  of  the  whole  science  and  practice 
of  mpdiciue.  and  will  be  fuuud  most  valuable  to  the 
practitioner  for  easy  reference,  and  especially  to  the 
student  in  attendance  upon  lectures,  whose  time  is 
too  much  occupied  with  many  studies,  to  consult  the 
larijer  works.  Such  a  work  must  always  be  in  great 
demand. — Cincinnati  Med.  Repertory,  Aov.  1871. 


ViTATSON  [THOMAS],  31.  D.,  ^c. 

LECTURES     ON     THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.     Delivered  at  King's  College,  London.     A  new  American,  from   the  Fifth  re- 
vised and  enlarged  English  edition.     Edited,   with  additions,  and  several  hundred  illus- 
trations, by  Henry  Hartshorne,  M.D.,  Professor  of  Hygiene  in  the  University  of  Penn- 
sylvania.  In  two  large  and  hauilsoine  8vo.  vols.   Cloth,  §9  01);  leather, $11  dO.    (J nut  ready.) 
With  the  assistance  of  Professor  George  Johnson,  his  successor  in  the  chair  of  Practice  of  Medi- 
cine in  King's  College,  the  author  has  thoroughly  revised  this  WQrk,  and  has  sought  to  bring  it 
on  a  level  with  the  most  advanced  condition  of  the    ubject.     As  he  himself  remarks  :   "Consider- 
ing the  rapid  advance  of  medical  science  during  the  last  fourteen  years,  the  present  edition  would 
be  worthless,  if  it  did  not  differ  much  from  the  last" — but  in  the  extensive  alterations  and  addi- 
tions that  have  been  introduced,  the  effort  of  the  author  has  been  to  retain  the  lucid  and  collo- 
quial style  of  the  lecture-room,  which  has  made  the  work  so  deservedly  popular  with  all  classes 
of  the  profession.    Notwithstanding  these  changes,  there  are  some  subjects  on  which  the  American 
reader  might  reasonably  expect  more  detailed  information  than  has  been  thought  requisite  in 
England,  and  these  deficiencies  the  editor  has  endeavored  to  supply. 

■  The  large  size  to  which  the  work  has  grown  seems  to  render  it  necessary  to  print  it  in  two  vol- 
umes, in  place  of  one,  as  in  the  last  American  edition.  It  is  therefore  presented  in  that  shape, 
handsomely  printed,  at  a  very  reasonable  price,  and  it  is  hoped  that  it  will  fully  maintain  the 
position  everywhere  hitherto  accorded  to  it,  of  the  standard  and  classical  representative  of  Eng- 
lish practical  medicine. 


At  length,  after  many  months  of  expectation,  we 
have  the  satisfaction  of  finding  ourselves  this  week  in 
possession  of  a  revised  and  enlarged  edition  of  Sir 
Tliomas  Watson's  celebrated  Lectures  It  is  a  sub- 
ject for  congratulation  and  for  thankfulness  that  Sir 
Thomas  Watson,  during  a  period  of  comparative  lei- 
bi-.re,  after  a  long,  laborious,  and  most  honorable  pro- 
fessional career,  while  retaining  full  possession  of  his 
high  mental  faculties,  should  have  employed  the  op- 
portunity to  submit  his  Lectures  to  a  more  thorough 
revision  than  was  possible  during  the  earlier  and 
busier  period  of  his  life.  Carefully  passing  in  review 
some  of  the  most  intricate  and  important  pathological 
and  practical  questions,  the  results  of  his  clear  iubight 
an.l  his  calm  judgment  are  now  recorded  for  the  bene- 
fit of  mankind,  in  language  which,  lor  precision,  vigor, 
and  classical  elegance,  has  rarely  been  equalled,  and 
never  surpassed  The  revision  has  evidently  been 
most  carefully  done,  and  the  results  appear  in  almost 
every  page. — Brit.  Med.  Jotirn.,  Oct.  14,  1871. 

No  words  can  convey  the  pleasurable  satisfaction 
that  we  feel  in  looking  over  the  revised  edition  of 
the  admirable  lectures  of  this  distinguished  author. 
The  earnestness  which  marked  his  whole  profes- 
sional career  leads  him,  in  a  chara<teristic  manner, 
to  devote  his  last  leisure  hours  to  the  correction  of  his 
great  clas-ic  work.  The  lectures  are  so  Wfll  known 
and  so  justly  appreciated,  that  it  is  scarcely  neces- 
s.'iy  to  do  more  than  call  attention  to  the  special 
advantages  of  the  last  over  previous  editions.  In 
the  revision,  the  author  has  displayed  all  the  charms 
and  ad  vantages  of  gieat  culture  and  a  ripe  experi- 
ence combined  with  the  soundest  judgment  and  sin- 


cerity of  purpose.  The  author's  rare  combination 
of  great  scientific  attainments  combined  with  won- 
derful forensic  eloquence  has  exerted  extraordinary 
influence  over  the  last  two  generations  of  physicians. 
His  clinical  descriptions  of  most  diseases  have  never 
been  equalled  ;  and  on  this  score  at  least  his  work 
will  live  long  in  the  future.  The  work  will  be 
sought  by  all  who  appreciate  a  great  book. — Amtr. 
Journal  of  Syphilographij,  July,  1872. 

We  are  exceedingly  gratified  at  the  reception  of 
this  new  edition  of  Watson,  pre-eminently  the  prince 
of  English  authors,  on  "Practice."  We,  who  read 
the  fir.st  edition  as  it  came  to  us  tardily  and  in  frag- 
ments through  the  "Medical  News  and  Library," 
shall  never  forget  the  great  pleasure  and  profit  we 
derived  from  its  graphic  delineations  of  disease,  its 
vigorous  style  and  splendid  English.  Maturity  of 
years,  extensive  observation,  profound  research, 
aud  yet  continuous  enthusiasm,  have  combined  to 
give  Us  in  this  latest  edition  a  in.idel  of  professional 
excellence  in  teaching  with  rare  beauty  in  the  mode 
of  commvinication.  But  this  ctaxiic  needs  no  eulo- 
gium  of  ours.  The  selection  of  Prof.  Harlshorne  as 
the  American  editor,  is  to  ns  peculiarly  gratifying, 
aud  must  in.sure  even  larger  popularity  and  mcire 
general  sale  to  American  readers.  Every  guarantee 
is  thus  afforded  that  in  every  part  the  book  will  be 
fou[i<l  up  to  the  times.  Will  it  do  to  repeat  the  re- 
mark we  have  seen  somewliere:  "  No  library  can  be 
ciinsidered  complete  without  it?"  Although  the 
phrase  may  not  savor  of  originality,  it  is,  neverthe- 
less, most  emphatically  true. — Vliicago  Med.  Journ., 
July,  1872. 


Henry  C.  Lea's  Publications — (Diseases  of  Lungs  and  Heart).     It 


J^LINT  [A  USTIN),  M.  D., 

■*-  Profesftor  of  the  Princ.iplen  and  Practice  of  MeAiclne  in  Bellevue  Honpital  Med.  Oollege,  N.  Y. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATiMENT  OF  DISEASES  OF   THE  HEART.     Second  revised  and  enlnrged 

edition.      In  one  octavo  volume  of  550  page.s,  V7ith  a  pl.ate,  extra  cloth,  $4.     (Just  Issued.) 

The  autlior  has  sedulously  inii)roved  the  opportunity  afforded  him  of  revising  this  work.   Portions 

of  it  have  been  rewritten,  and  the  whole  brought  up  to  a  level  with  the  most  advanced  condition  of 

science.   It  must  therefore  continue  to  maintain  its  position  as  the  standard  treatise  on  the  subject. 


Dr.  Flint  chosea  difTu-ull  subject  for  his  researches, 
and  has  sluiwn  reniitrkable  powers  of  ohservatioQ 
ami  rellection,  as  well  as  i;i'fat  industry,  in  his  treat- 
ment of  it.  His  book  must  be  considered  the  fullest 
and  clearest  practical  treatise  on  those  subjects,  and 
should  be  in  the  hands  of  all  practitioners  and  stu- 
dents. It  is  a  credit  to  American  medical  literature. 
— Ainer.  Journ.  of  the  Med.  Scitncus,  July,  18<i0. 

We  question  the  fact  of  any  recent  American  author 
In  our  profession  being  more  extensively  known,  or 
more  deservedly  esteemed  in  this  country  than  Dr. 
Flint.  We  willingly  acknowledge  his  success,  more 
particularly  in  the  volume  on  diseases  of  the  heart, 
In  making  an  extended  personal  clinical  study  avail- 


able for  purposes  of  illustration,  in  connection  with 
cases  which  have  been  reported  by  other  trustworthy 
observers. — Brit,  and  For.  Med.-Vhirv.rg.  Review. 

In  regaid  to  the  merits  of  the  work,  we  have  no 
hesitatiou  in  pronouncing  it  full,  accurate,  and  judi- 
cious. Considering  the  present  slate  of  science,  such 
a  work  wa.s  much  needed.  It  sliould  be  iu  the  hands 
of  every  practitioner. — Chicago  Mtd.  Journ. 

With  more  than  pleasure  do  we  hail  the  advent  of 
this  work,  for  it  fills  a  wide  gap  on  the  list  of  text- 
books for  our  schools,  and  is,  for  the  practitioner,  the 
most  valuable  practical  work  of  its  kind. — N.  0.  Med. 
News. 


DY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATLSE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  extra  cloth,  $4  50. 


Dr.  Flint's  treatise  is  one  of  the  most  trustworthy 
guides  which  he  can  consult.  The  style  is  clear  and 
distinct,  and  is  also  concise,  being  free  from  that  tend- 
ency to  over-refinement  and  unnecessary  minuteness 
which  characterizes  many  works  on  the  same  s\ih- 
jwt.— Dublin  Medica.l  Press,  Feb.  6,  1867. 

The  chapter  on  Phthisis  is  replete  with  Interest ; 
and  his  remarks  on  the  diagnosis,  especially  in  the 
early  stages,  are  remarkable  for  their  acumen  and 
great  practical  value.  Dr.  Flint's  style  is  clear  and 
elegant,  and  the  tone  of  freshness  and  originality 


wliich  pervades  his  whole  work  lend  an  additional 
force  to  its  thoroughly  practical  character,  which 
cannot  fail  to  obtain  for  it  a  place  as  a  standard  work 
on  diseases  of  the  respiratory  system. — London 
Lancet,  Jan.  19,  1867. 

This  is  an  admirable  book.  Excellent  in  detail  and 
execution,  nothing  better  could  be  desired  by  tbe 
practitioner.  Dr.  Flint  enriches  his  subject  with 
much  solid  and  not  a  little  original  observation. — 
Ranking's  Abstract,  Jan.  lSt)7. 


JPULLER  [HENRY  WILLIAM),  M.  D., 

-*■  Physician  to  fit.  George's  Hospital,  London. 

ON  DISEASES  OF  THE   LUNGS   AND   AIR-PASSAGES.     Their 

Pathology,  Physical  Diagnosis,  Symptoms,  and  Treatment.     From  the  second  and  revised 
English  edition.     In  one  handsome  octavo  volume  of  about  500  pages,  extra  cloth,  $3  50. 


Dr.  Fuller's  work  on  diseases  of  the  chest  was  so 
favorably  received,  that  to  many  who  did  not  know 
the  extent  of  his  engagements,  it  was  a  matter  of  won- 
der that  it  should  be  allowed  to  remain  three  years 
out  of  print.  Determined,  however,  to  improve  it. 
Dr.  Fuller  would  not  consent  to  a  mere  reprint,  and 


accordingly  we  have  what  might  be  with  perfect  jus- 
tice styled  an  entirely  new  work  from  his  pen.  the 
portion  of  the  work  treating  of  the  heart  and  great 
vessels  being  excluded.  Nevertheless,  this  volume  is 
of  almost  equal  size  with  the  first. — London  Medical 
Times  and  Gazette,  July  2C,  1867. 


jyiLLIA3IS  (C  /.  B.),  M.D., 

Senior  Consulting  Phyncian  to  the  Hospital  for  Oonsumxition,  Brampton,  and 

\yiLLIAMS  [CHARLES  T.),  M.D., 

Physician  to  the  Hospital  for  Consumption. 

PULMONARY  CONSUMPTION;  Its  Nature,  Yarietie.s,  and  Treat- 

ment.     With  an  Analysis  of  One  Thousand  cases  to  exemplify  its  duration.     In  one  neat 
octavo  volume  of  about  350  pages,  extra  cloth.      (Just  Issued.)     $2  50. 


He  can  still  speak  from  a  more  enormous  experi- 
ence, and  a  closer  study  of  the  morbid  processes  in- 
volved iu  tuberculosis,  than  most  living  men.  He 
owed  it  to  himself,  and  to  the  importance  of  tbe  sub- 
ject, to  embody  his  views  in  a  separate  work,  and 
we  are  glad  that  he  has  accomplished  this  duty. 
After  all,  the  grand  teaching  which  Dr  Williams  has 
for  the  profession  is  to  be  found  in  his  therapeutical 
chapters,  and  in  the  history  of  individual  cases  ex- 
tended, by  dint  of  care,  over  ten,  twenty,  thirty,  and 
even  forty  years. — London  Lancet,  Oct.  21,  1871. 

His  results  are  more  favorable  than  those  of  any 


previous  author;  but  probably  there  is  no  malady, 
the  treatment  of  which  has  been  so  much  improved 
within  Ihe'ast  twenty  years  as  pulmonary  consump- 
tiou.  To  ourselves.  Dr.  Williams's  chapters  on  Treat- 
ment are  amongst  the  most  valualile  and  attractivein 
the  book,  and  would  alone  render  it  a  standard  work 
of  reference.  In  conclusion,  we  would  record  our 
opinion  that  Dr.  Williams's  great  reputaiion  is  fully 
maintained  by  this  book.  It  is  undoubtedly  one  of 
the  most  valuable  works  in  the  language  upon  any 
special  disease. — Land.  Med.  Times  and  Gaz.,  Nov. 
4,  1871. 


LA   ROCHE  ON  PNEUMONIA.     1  vol.  8vo.,  extra  \  SMITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE- 


cloth,  of  500  pages.     Price  $3  00 

BUCKLER  ON    FIBRO-BRONCHITIS  AND  RHEU- 
MATIC PKEU.MONIA.     1  vol.  8vo.     $1   2.0. 

FISKE  FUND  PRIZE  ESSAYS  ON  CONSUMPTION. 
1  vol  8vo,,  extra  cloth.     ^100. 


MKDIABLE  STAGES.     1  vol.  8vo.,  pp.  254.     *2  25. 
SALTER  ON  ASTHMA.     1  vol.  8vo.     $2  .50. 
WALSHE  ON  THE  DISEASES  OF  THE  HEART  AND 

GREAT  VESSELS.     Third  American   edition.     In 

1  vol.  8 vo.,  420  pp.,  cloth.     $3  00. 


18 


Henry  C.  Lea's  Publications — {Practice  of  Medicine). 


£1 

A 


PO BERTS  (  WILLIAM),  M.  Z>., 

Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  Ac. 

PRACTICAL  TREATISE   OX  URINARY  AND   RENAL   DIS- 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engravings.  Sec- 
ond American,  from  the  Second  Revised  and  Enlarged  London  Edition.  In  one  large 
and  handsome  octavo  volume  of  616  pages,  with  a  colored  plate  ;  extra  cloth,  $4  50.  {Just 
Ready.) 

The  author  has  subjected  this  work  to  a  very  thorough  revision,  and  has  sought  to  embody  in 
it  the  re.^ults  nf  the  latest  experience  and  investigations.  Although  every  effort  has  been  made 
to  keep  it  within  the  limits  of  its  former  size,  it  has  been  enlarged  by  a  hundred  pages,  many 
new  wood-cuts  have  been  introduced,  and  also  a  colored  plate  representing  the  appearance  of  the 
different  varieties  of  urine,  while  the  price  has  been  rettiined  at  the  former  veiy  moderate  rate. 
In  every  respect  it  is  therefore  presented  as  worthy  to  maintain  the  position  whieh.it  has  acquired 
as  a  leading  authorit}'  on  a  large,  important,  and  perplexing  class  of  affections.  A  few  notices 
of  the  first  edition  are  appended. 


The  plan,  it  will  thus  be  seen,  is  very  complete, 
anl  the  manner  in  which  it  has  been  carried  out  is 
in  the  highest  degree  satii^factory.  The  characters 
of  tlie  different  deposits  are  very  well  described,  and 
the  microscopic  appearances  they  pre.sent  are  illus- 
trated by  numerous  well  executed  engravings.  It 
only  remains  to  us  to  strongly  recommend  to  our 
readers  Dr.  Roberts's  work,  as  containing  an  admira- 
ble risrL'nit  of  the  present  state  of  knowledge  of  uri- 
nary diseases,  and  as  a  safe  and  reliable  guide  to  the 
clinical  observer. — Edin.  Med.  Jour. 

The  most  complete  and  practical  treatise  upon  renal 


diseases  we  have  examined.  It  is  peculiarly  adapted 
to  the  wants  of  the  majority  of  American  practition- 
ers from  its  clearness  and  simple  announcement  of  the 
facts  in  relation  to  diagnosis  and  treatment  of  urinary 
disorders,  and  contains  in  condensed  form  the  investi- 
gations of  Bence  Joues,  Bird,  Beale,  Hassall.  Prout, 
and  a  host  of  other  well-known  writers  upon  this  sub- 
ject. The  characters  of  urine,  physiological  and  pa- 
thological, as  indicated  to  the  naked  eye  as  well  as  by 
microscopical  and  chemical  investigations,  are  con- 
cisely represented  both  by  description  and  by  well 
executed  engravings. — Cincinnati  Journ.  of  Med. 


B 


ASEA31  {W.R.),  M.D., 

Senior  Physician  to  the  Westminster  Hospital,  &c. 

RENAL  DISEASES:  a  Clinical  Guide  to  their  Diagnosis  and  Treatment. 

With  illustrations.     In  one  neat  royal  12mo.  volume  of  304  pages.    $2  00.     {Just  Issued.) 

The  chapters  on  diagnosis  and  treatment  are  very  j  raent  render  the  book  pleasing  and  convenient. — Am,. 


good,  and  the  student  and  young  practitioner  will 
find  tReni  full  of  valuable  practical  hints.  The  third 
part,  on  the  urine,  is  excellent,  and  we  cordially 
recommend  its  perusal.  The  author  has  arranged 
his  matter  in  a  somewhat  novel,  and,  we  think,  use- 
ful form.  Here  everything  can  be  easily  found,  and, 
what  is  more  important,  easily  read,  for  all  the  dry 
details  of  larger  books  here  acquire  a  new  interest 
from  the  author's  arrangement.  This  part  of  the 
book  is  full  of  good  work. — Brit,  and  For.  Medico- 
Chirurgical  Keview,  July,  1870. 

The  easy  descriptions  and  compact  modes  of  state- 


Journ.  Med.  Sciences,  July,  1S70. 

A  book  that  we  believe  will  be  found  a  valuable 
assistant  to  the  practitioner  and  guide  to  the  student. 
— Baltimore  Med.  Journal,  July,  1870. 

The  treatise  of  Dr.  Basham  differs  from  the  rest  in 
its  special  adaptation  to  clinical  study,  and  its  con- 
densed and  almost  aphorisrnal  style,  which  makes  it 
easily  read  and  easily  understood.  Besides,  the 
author  expresses  some  new  views,  which  are  well 
worthy  of  consideration.  The  volume  is  a  valuable 
addition  to  this  department  of  linowledge. — Pacific 
Med.  and  Surg.  Journal,  July,  1870. 


MORLAND  ON  RETENTION  IN  THE 
1  vol.  Svo.,  extra  cloth.    75  cents. 

TONES  [G.  HANDFIELD),  M. 

"  Physician  to  St.  Mary's  Hospital,  &c. 


BLOOD  OF  THE  ELEMENTS  OF  THE  URINARY    SECRETION. 


D., 


OBSERVATIONS 

Second  American  Edition. 
25. 


CLINICAL 

DISORDERS, 
extra  cloth,  $.3 

Taken  as  a  whole,  the  work  before  us  furnishes  a 
short  but  reliable  account  of  the  pathology  and  treat- 
ment of  a  class  of  very  common  but  certainly  highly 
obscure  disorders.  The  advanced  student  will  find  it 
a  rich  mine  of  valuable  facts,  while  the  medical  prac- 
titioner will  derive  from  it  many  a  suggestive  hint  to 
aid  him  in  the  diagnosis  of  "nervous  cases,"  and  in 
determining  the  true  indications  for  their  ameliora- 
tion or  CMve.—Amer.  Journ.  Med.  Sci.,  Jan.  1867. 


ON    FUNCTIONAL   NERVOUS 

In  one  handsome  octavo  volume  of  348  pages. 


We  must  cordially  recommend  it  to  the  profession 
of  this  country  as  supplying,  in  a  great  measure,  a 
deficiency  which  exists  in  the  medical  literature  of 
the  English  language. — New  York  Med.  Journ.,  April, 
1867. 

The  volume  is  a  most  admirable  one — full  of  hints 
and  practical  suggestions.  —  Canada  Med.  Journal, 
April,  1867. 


0 

s 


N  DISEASES  OF  THE  SPIRAL  COLUMN  AND  OF  THE  NERVES. 
By  C.  B.  Eadclifp,  M.  D.,  and  others.     1  vol.  8vo.,  extra  cloth,  $1  50. 


LADE  [D.  D.),  M.D. 

DIPHTHERIA;  its  Nature  and  Treatment,  with  an  account  of  the  His- 
tory of  its  Prevalence  in  various  Countries.  Second  and  revised  edition.  In  one  neat 
royal  12mo.  volume,  extra  cloth.     $1  25. 


H 


UDSON  {A.),  M.  D.,  M.  R.  1.  A., 

PUyfiician  to  the  .Meath  Hofipital. 

LECTURES  ON  THE    STUDY  OF  FEYER.     In   one  vol.  8vo.,  extra 

Cloth,  $2  50. 
TTONS  [ROBERT  D.),  K~C~C. 
A  TREATISE  ON  FEYER;  or,  Selections  from  a  Course  of  Lectures 

on  Fever.    Being  part  of  a  Course  of  Theory  and  Practice  of  Medicine.    In  one  neat  ootavo 
volume,  of  362  pages,  extra  cloth.     $2  25. 


Henry  C.  Lea's  Publications — ( Venereal  Diseases,  etc.). 


19 


L> UMS TEAD  {FREEMAN  J.),  M.D., 

-*-'         Pri>/c.ti«ir  of  Vene.rndl  DiKKases  ntthe  Old.  of  Phys.  and  Rurg.,  New  York,  Ac. 

THE    PATHOLOGY  AND   TREATMENT   OF   VENEREAL  DIS- 
EASES.    Incluilinp;  the  results  of  recent  investigations  upon  the  subject.     Third  edition, 
reri.sed  and  enliirjit'd,  with  illustrations.     In  one  large  and  handsome  octavo  volume  of 
over  TOO  piiRes,  extra  cloth,  $f)  00;  leatlier,  $0  00.      {Ju.st  Issiwd.) 
In  prt'p;iriiig  this!  standard  work  again  for  tlie   press,  the  author  has  subjected  it   to  a  very 
thorough  revision.     Many  portions  have  been  rewritten,  and  much  new  matter  added,  in  order  to 
bring  it  completely  on  a  level  with  the  most  advanced  condition  of  sypliilography,  but  by  careful 
compression  of  the  text  of  jjvevious  editions,  the  work  has  been  incrensed  by  only  sixty-four  pages. 
The  labor  thus  bestowed  upon  it,  it  is  hoped,  will  insure  for  it  a  continuance  of  its  position  as  a 
complete  and  trustworthy  guide  for  the  practitioner. 


It  is  the  most  complete  book  with  which  we  are  ac- 
quaiuted  in  the  laugiiaji;©.  The  latest  views  of  the 
best  authorities  are  put  forward,  and  the  iafovmation 
is  well  arranged — a  great  point  for  the  student,  and 
still  move  for  the  pvactilionor.  The  subjects  of  vis- 
ceral syphilis,  syphilitic  all'ections  nf  tlie  eyes,  and 
the  treatment  of  syphilis  by  repeatedinoculations,  are 
very  fnlly  discussed. — London  Lanett,  Jan.  7,  IS71. 

Dr.  Bumstead's  work  is  already  so  universally 
known  as  the  best  treatise  in  the  English  language  on 
venereal  diseases,  that  it  may  seem  almost  superflu- 
ous to  say  more  of  it  than  that  a  new  edition  has  been 
issued.  Hut  the  author's  industry  has  rendered  this 
aew  edition  virtually  a  new  work,  and  so  merits  as 


much  special  commendation  as  if  its  predecessors  had 
not  been  published.  As  a  thoroughly  practical  book 
on  a  class  of  diseases  which  form  a  large  share  of 
nearly  every  physician's  practice,  the  volume  before 
us  is  bv  far  the  best  of  which  we  have  knowledge. — 
N.   Y.  Me.dicnl  OnzMte,  Jan.  28,  1S71. 

It  is  rare  in  the  history  of  medicine  to  find  any  one 
book  which  contains  all  that  a  practitioner  needs  to 
know;  while  the  possessor  of  "Bumstead  on  Vene- 
real" has  no  occasion  to  look  outside  of  its  covers  for 
anything  practical  connected  with  the  diagnosis,  his- 
tory, or  treatment  of  these  allections. — N.  Y.  Medical 
Journal,  March,  1871. 


JDUMSTEAD  [FREEMAN  J.), 

-'-'       Proff-isor  of  Venereal  Diseases  in  the  C 


College  of 


(lULLERIER  [A.),  and 

V-/  Surgeon  to  the  Hdpital  dti  Midi. 

Physicians  and  Surgeons,  N.  Y. 

AN  ATLAS  OF  VENEREAL  DISEASES.     Translated  and  Edited  by 

Freeman  J.  Bumstead.  In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 
with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 
life:  strongly  bound  in  extra  cloth,  $17  00;  also,  in  five  parts,  stout  wrappers  for  mailing,  at 
$3  per  part.      (^Lately  Ptihlished.)  • 

Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  Three  Dol- 
lars a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of  prac- 
tice.    Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without  delay. 
A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 


We  wish  for  once  that  our  province  was  not  restrict- 
ed to  methods  of  treatment,  that  we  might  say  some- 
thing of  the  exquisite  colored  plates  in  this  volume, 
— London  Practitioner,  May,  1869. 

As  a  whole,  it  teacl;es  all  that  can  be  taught  by 
means  of  plates  and  print. — London  Lancet,  March 
13,  1665. 

Superior  to  anything  of  the  kind  ever  before  issued 
on  this  continent. — Canada.  Med.  Journal,  March,  '69. 

The  practitioner  who  de.sires  to  understand  this 
branch  of  medicine  thoroughly  should  obtain  this, 
the  most  complete  and  best  work  ever  published. — 
Dominion  Med.  Journal,  May,  1869. 

This  is  a  work  of  master  hands  on  both  sides.  M. 
CuUerier  is  scarcely  second  to,  we  think  we  may  truly 
say  is  a  peer  of  the  illustrious  and  venerable  Ricord, 
while  in  this  country  we  do  not  hesitate  to  say  that 
Dr.  Bumstead,  as  an  authority,  is  without  a  rival. 
Assuring  our  readers  that  these  illustrations  tell  the 
whole  history  of  venereal  disease,  from  its  inception 
to  its  end,  we  do  not  know  a  single  medical  work. 


which  for  its  kind  is  more  necessary  for  them  to  have. 
— Calif  yrnia  Med.  Gazette,  March,  1869. 

The  most  splendidly  illustrated  work  in  the  lan- 
guage, and  in  our  opinion  far  more  useful  than  the 
French  original. — Am.  Journ.  Med.  Sciences,  Jan. '69. 

The  fifth  and  concluding  number  of  this  magnificent 
work  has  reached  us,  and  we  have  no  hesitation  in 
saying  that  its  illustrations  surpass  those  of  previous 
numbers.— £osio»  Med.  and  Surg.  Journal,  Jan.  14, 
1869. 

Other  writers  besides  M.  CuUerier  have  given  us  a 
good  account  of  the  diseases  of  which  he  treats,  but 
no  one  has  furnished  us  with  such  a  complete  series 
of  illustrations  of  the  venereal  diseases.  There  is, 
however,  an  additional  interest  and  value  possessed 
by  the  volume  before  us  ;  foritis  an  American  reprint 
and  translation  of  M.  CuUorier's  work,  with  inci- 
dental remarks  by  one  of  the  most  eminent  American 
syphilographers,  Mr.  Bumstead. — Brit,  and  For. 
iledico-Ohir.  Review,  July,  1S69. 


// 


7LL  [BERKELEY), 

Surgeon  to  the  Lock  Hospital,  London. 


ON  SYPHILIS  AND  LOCAL 

one  handsome  octavo  volume  ;  extra  cloth 

Bringing,  as  it  does,  the  entire  literature  of  the  dis- 
ease dowu  to  the  present  day,  and  giving  with  great 
ibility  the  results  of  modern  research,  it  is  in  every 
respect  a  most  desirable  work,  and  one  which  should 
find  a  place  in  the  library  of  every  surgeon. — Cali- 
fornia Med.  Gazette,  June,  1869. 

Considering  the  scope  of  the  book  and  the  careful 
attention  to  the  manifold  aspects  and  details  of  its 
subject,  it  is  wonderfully  concise.  All  these  qualities 
render  it  an  especially  valuable  book  to  the  beginner. 


In 


CONTAGIOUS  DISORDERS. 

,  $3  25.     {Lately  Published.) 

to  whom  we  would  most  earnestly  recommend  its 
study  ;  while  it  is  no  less  useful  to  the  practitioner. — 
St.  Louis  Med.  and  Surg.  Journal,  May,  1869. 

The  most  convenient  and  ready  book  of  reference 
we  have  met  with.— iV^.  r.  Med.  Record,  May  1, 1869. 

Most  admirably  arranged  for  both  student  and  prac- 
titioner, no  other  work  on  the  subject  equals  it ;  it  is 
more  simple,  more  easily  studied. — Buffalo  3Ied.  and 
Surg.  Journal,  March,  1869. 


^EISSL  [H.],  M.D. 

A  COMPLETE  TREATISE  ON  VENEREAL  DISEASES.  Trans- 
lated from  the  Second  Enlarged  Germnn  Edition,  by  Frederic  R.  Sturgis,  M.D.  In  one 
octavo  volume,  with  illustrations.      {Preparing.) 


20 


Henry  C.  Lea's  Publications — {Diseases  of  the  Skin). 


TU^ILSON  {ERASMUS),  F.R.S. 

ON  DISEASES  OF  THE  SKIN.  With  Illustrations  on  wood.  Sev- 
enth American,  from  the  sixth  and  enlarged  English  edition.  In  onelarge  octavo  volume 
of  over  800  pages,  $5. 

A  SERIES   OF   PLATES   ILLUSTRATING  "WILSON   ON  DIS- 

EASES  OF  THE  SKIN;"  consisting  of  twenty  beautifully  executed  plates,  of  which  thir- 
teen are  exquisitely  colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin, 
and  embracing  accurate  representations  of  about  one  hundred  varieties  of  disease,  most  of 
them  the  size  of  nature.     Price,  in  extra  cloth,  $5  50. 
Also,  the  Text  and  Plates,  bound  in  one  handsome  volume.     Extra  cloth,  $10. 

No  one  treating  skin  diseases  should  he  without 
a  copy  of  this  standard  work. —  Canada  Lancet, 
iugust,  1863. 

We  can  safely  recommend  it  to  the  profession  as 
the  best  work  on  the  subject  now  in  existence  in 
the  English  language. — Medical  Times  and  Gazette. 


Sucti  a  work  as  the  one  before  us  is  a  most  capita! 
aad  acceptable  help.  Mr.  Wilson  has  long  been  held 
as  high  authority  in  this  department  of  medicine,  and 
his  book  on  diseases  of  the  skin  has  long  been  re- 
garded as  one  or  the  best  text-books  extant  on  the 
subject.  The  present  edition  is  carefully  prepared, 
Aud  brought  up  in  its  revision  to  the  present  time.  In 
th's  edition  we  have  also  included  the  beautiful  series 
of  plates  illustrative  of  the  text,  and  in  the  last  edi- 
tion published  separately.  There  are  twenty  of  these 
plates,  nearly  all  of  them  colored  to  nature,  and  ex- 
hibiting with  great  tidelity  the  various  groups  of 
diseases. — Cincinnati  Lancet. 


Mr.  Wilson's  volume  is  an  excellent  digest  of  the 
actual  amount  of  knowledge  of  cutaneous  diseases; 
it  includes  almost  every  fact  or  opinion  of  importance 
connected  with  the  anatomy  and  pathology  of  the 
skin. — British  and  Foreign  Medical  Review. 


B 


T  THE  SAME  AUTHOR. 


THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  Dis- 

EASES  OF  THE  SKIN.    In  One  Very  handsome  royal  12mo.  volume.    $3  60.    (Lately  Issued.) 


J^ELIGAN  {J.MOORE),  M.D.,M.R.I.A. 

A    PRACTICAL    TREATISE    ON    DISEASES    OF    THE    SKIN. 

Fifth  American,  from  the  second  and  enlarged  Dublin  edition  by  T.  W.  Belcher,  M.  D. 
In  one  neat  royal  12mo.  volume  of  462  pages,  extra  cloth.     $2  25. 


Fully  equal  to  all  the  requirements  of  students  and 
young  practitioners. — Dublin  Med.  Press. 

Of  the  remainder  of  the  work  we  have  nothing  be- 
yond unqualified  commendation  to  offer.  It  is  so  far 
the  most  complete  one  of  its  size  that  has  appeared, 
and  for  the  student  there  can  be  none  which  can  com- 
pare with  it  in  practical  value.  All  the  late  disco- 
veries in  Dermatology  have  been  duly  noticed,  and 

)r   THE  SAME  AUTHOR.  — 


•heir  value  justly  estimated;  in  a  word,  the  work  is 
fully  up  to  the  times,  and  is  thoroughly  stocked  with 
most  valuable  information. — New  York  Med.  Record, 
Jan.  16,  1&67. 

The  most  convenient  manual  of  diseases  of  the 
skin  that  can  be  procureo  by  the  student. — Chicago 
Med.  Journal,  Dec.  1866. 


B' 


ATLAS   OF   CUTANEOUS    DISEASES.      In   one  beautiful   quarto 

volume,  with  exquisitely  colored  plates,  &g.,  presenting  about  one  hundred  varieties  of 
disease.     Extra  cloth,  $5  50. 


The  diagnosis  of  eruptive  disease,  however,  under 
all  circumstances,  is  very  difficult.  Nevertheles.s, 
Dr.  Neligan  bas  certainly,  "as  far  as  possible,"  given 
a  faithful  and  accurate  represeatation  of  this  class  of 
diseases,  and  there  can  be  no  doubt  that  these  plates 
will  he  of  great  use  to  the  student  and  practitioner  in 
drawing  a  diagnosis  as  to  the  class,  order,  and  species 
to  which  the  particular  case  may  belong.  While 
looking  over  the  "Atlas"  we  have  been  induced  to 
examine  also  the  "Practical  Treatise,"  and  we  are 


inclined  to  con.sider  it  a  very  superior  work,  com- 
bining accurate  verbal  description  with  sound  vievv's 
of  the  pathology  and  treatmeut  of  eruptive  diseases. 
—  Gla-sgino  Med.  ■Journal. 

A  compend  wliich  will  very  much  aid  the  practi- 
tioner in  this  difficult  branch  of  diagnosis  Taken 
with  the  beautiful  plates  of  the  jVtlas,  which  are  re- 
markable for  their  accuracy  and  beauty  of  coloring, 
it  constitutes  a  very  valuable  addition  to  the  library 
of  a  practical  man. — Buffalo  Med.  Journal. 


TJILLIER  {THOMAS),  M.D., 

-*  Pky.iicinn  to  the  Skin  Department  of  University  College  Hospital,  &c. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

Second  American  Edition.     In  one  royal  12mo.  volume  of  358  pp.     With  Illustrations. 
Extra  cloth,  $2  25. 


We  can  conscientiously  recommend  it  to  the  stu- 
dent; the  style  is  clear  and  pleasant  to  read,  the 
matter  is  good,  and  the  descriptions  of  disease,  with 
the  modes  of  treatment  recommended,  are  frequently 
Illustrated  with  well-recorded  cases. — London  Med. 
I^mes  and  Gazette,  April  1,  1865. 


It  is  a  concise,  plain,  practical  treatise  on  the  vari- 
ous diseases  of  the  skin  ;  just  such  a  work,  indeed, 
as  was  much  needed,  both  by  medical  students  and 
practitioners.  —  Chicago   Medical  Examiner,   May, 

1865. 


A  NDERSON  {McCALL),  M.D., 

-^^  Pliy.'iician  to  the  Disiiensnrji  for  Skin  Diseases,  Glasgow,  Ae. 

ON  THE  TREATMENT  OF  DISEASES  OF  THE  SKIN.     With  an 

Annlysis  of  Eleven  Thousand  Consecutive  Cases.     In  one  vol.  Svo.      {Publisking  in  ths 

Medical  News  aiid  Library  for  1873.) 
The  very  practical,  character  of  this  work  and  the  extensive  experience  of  the  .author,  cannot 
fail  to  render  it  acceptable  to  the  subscribers  of  the   "  A\iEKit;.\.v  JoiJH>fAL  of  thk   Mkrical, 
Sciences."     When  completed  in  the  "New.s  and  Library,"  it  will  be  issued  separately  in  a 
neat  octavo  volume. 


Henry  C.  Lea's  Publications — (Diseases  of  Children).  21 


UMITH  {J.  LK  WIS).  M.  D., 

'^  Pni/fuxiir  1)/  Mnrhid  Anntnmy  in  the  FeUnmic  Hnnpifnl  Med.  C'dlegu,  N    Y. 

A  COMPLI-yrE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.     Second  Editiop,  revised  iind  grently  enlnrged.      In  one  handsome  octavo 
volume  ol'  742  pages,  ektra  cloth,  $5;   leather,  $6.     (Now  Ready.) 

FnOM  THE  PUEFACE  TO  THE  SECOND  EDITION. 

In  presenting  to  the  profession  the  second  edition  of  his  work,  the  author  gratefully  acknow- 
ledges the  fiivoriible  reception  accorded  to  the  first.  lie  has  endeavored  to  merit  a  continuance 
of  this  approbation  hy  rendering  the  volume  much  more  complete  than  before.  Nearly  twenty 
additional  disea.'^es  have  been  treated  of,  among  which  may  be  named  Diseases  Incidental  to 
Birth,  R:iehitis,  Tuberculosis,  Scrofula,  Intermittent,  Remittent,  and  Typhoid  Fevers,  Chorea, 
and  the  various  forms  of  Paralysis.  Many  new  formuliB,  which  experience  has  shown  to  be 
useful,  have  been  introduced,  portions  of  the  text  of  a  less  practical  n;iture  have  been  con- 
densed, and  other  portions,  especially  those  relating  to  pathological  histology,  have  been 
rewritten  to  correspond  with  recent  discoveries.  Every  effort  has  been  made,  however,  to  avoid 
an  undue  enlargement  of  the  volume,  but,  notwithstanding  this,  and  an  increase  in  the  size  of 
the  page,  the  number  of  pages  has  been  enlarged  by  more  than  one  hundred. 

227  West  49th  Street,  New  York,  April,  1872. 

The  work  will  be  found  to  contain  nearly  one-third  more  matter  than  the  previous  edition,  and 
it  is  confidently  presented  as  in  every  respect  worthy  to  be  received  as  the  standard  American 
text-book  on  the  subject. 


Eniineotly  practical  as  well  as  judicious  in  its 
teachings. — Oincinntiti  Lancd  and  Obs.,  July,  1872. 

A  .standard  work  that  leaves  little  to  be  desired. — 
Indiana  Jimrnal  of  Medicine,  July,  1872. 

We  know  of  no  book  on  this  subject  that  we  can 
more  cordially  recommend  to  the  medical  student 
and  tbepractitioner. — Cincinnati  Clinic,  June29,  '72. 


We  regard  it  as  superior  to  any  other  single  work 
on  the  di-ieases  of  infancy  and  childhood. — Detroit 
Rev.  of  Med.  and  Pharmacy,  Aug.  1S72. 

We  confess  to  increased  enthusiasm  in  recommend- 
ing this  second  edition. — St  Louis  Med.  and  Surg. 
Journal,  Aug.  1S72. 


ftONDIE  {D.  FRANCIS),  M.D. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN. 

Sixth  edition,  revised  and  augmented.     In  one  large  octavo  volume  of  nearly  800  closely- 
printed  pages,  extra  cloth,  $6  25  f  leather,  $6  25.       (Lately  Issued.) 

The  present  edition,  which  is  the  sixth,  is  fully  up  I  teachers.  As  a  whole,  however,  the  work  is  the  best 
to  the  times  in  the  discussion  of  all  those  points  in  the  |  imerican  one  tliat  we  have,  and  in  its  special  adapt a- 
pathology  and  treatment  of  infantile  diseases  which  I  tion  to  American  practitioners  it  certainly  has  no 
have  been  brought  forward  by  the  German  and  French  |  equal.  —  New  York  Med.  Record,  March  2,  1S6S. 


l^EST  {CHARLES),  M.D., 

'  '  Physician  to  the  Hospital  for  Sick  Children,  A-c. 

LECTURES  ON   THE   DISEASES   OP   INFANCY  AND  CHILD- 

HOOD.  Fourth  American  from  the  fifth  revised  and  enlarged  English  edition.  In  one 
large  and  handsome  octavo  volume  of  656  closely-printed  pages.  Extra  cloth,  $4  60  ; 
leather,  $5  50. 

Of  all  the  English  writers  on  the  diseases  of  chil-  I  living  authorities  in  the  difBcult  department  of  medi- 
dren,  there  is  no  one  so  entirely  satisfactory  to  us  as  |  cal  science  in   which  he  is   must   widely  linown. — 
Dr.  West.     For  years  we  have  held  his  opinion  as  I  Boston  Med.  and  Surg.  Journal,  April  26,  1866. 
judicial,  and  have  regarded  him  as  one  of  the  highest  | 


DF  TEE  SAME  AUTHOR.     (Lately  Issued  ) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 

HOOD;  being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  of  Lon- 
don, in  March,  1871.     In  one  volume,  small  ]2mo.,  extra  cloth,  $1  00. 


^MITH [EUSTACE),  M.  D., 

Physician  to  the  Northwest  London  Free  Dispensary  for  Sick  Children. 

A  PRACTICAL  TREATISE   ON   THE  WASTIN(J   DISEASES  OF 

INFANCY  AND  CHILDHOOD.     Second  American,  from  the  second  revised  and  enlarged 
English  edition.     In  one  handsome  octavo  volume,  extra  cloth,  $2  50.      (Lately  Issued.) 

scribed  as  a  practical  handbook  of  the  common  dis- 
eases of  children,  so  numerous  are  the  alfectiuns  con- 
sidered either  collaterally  or  directly.  We  are 
acquainted  with  no  safer  guide  to  the  treatment  of 
children's  diseases,  and  few  works  give  the  insight 
into  the  physiological  and  other  peculiarities  of  chil- 
dren that  Dr.  Smith's  book  dues. — Brit.  Med.  Journ., 
April  S,  1S71. 


This  is  in  every  way  an  admirable  book.  The 
modest  title  which  ihe  author  has  chosen  for  it  scarce- 
ly conveys  an  adequate  idea  of  the  many  subjects 
upon  which  it  Ireais.  Wasting  is  so  constant  an  at- 
tendant upon  the  maladies  of  childhood,  thHt  a  trea- 
tise upon  the  wasting  diseases  of  children  must  neces 
sarily  embrace  the  consideration  of  many  atfeclions 
of  which  it  is  a  symptom  ;  and  this  is  excellently  well 
done  by  Dr.  Smith.     The  book  might  fairly  be  de- 


QUERSANT  {P.),  M.  D., 

Honorary  Surgeon  to  the  HospUalfor  Sick  Children,  Paris. 

SURGICAL  DISEASES  OF  INFANTS  AND  CHILDREN.     Trans- 

lated  by  R.  J.  Dunglison,  M.  D.     In  one  neat  octavo  volume,  extra  cloth,  $2  50.      (Nojv 
Ready  ) 

©■BWEES  ON  THE  PHYSICAL  AND  MEDICAL  TKEATMENT  OF  CHILDEEN.     Eleventh  edition.     1  vol. 
8to.  of  648  pages.     $2  80. 


h 


22 


Henry  C.  Lea's  Publications — (Diseases  of  Women). 


A  VELING  (JAMES  //.), 

-^T-  Phy-sieinn  to  the  Hospital  jf 


Chihtren. 


nnd 
Women  and 


ryiLTSHlRE  [ALFRED),  M.D., 

'  '  Assistant  Pfii/xifiaii-Acooucheur  to  St. 

Mary's  Hospital. 

THE    OBSTETRICAL    JOURNAL    of   Great   Britain    and  Ireland; 

Including  Midwiferv,  nnd  the  Diseases  op  Women  and  Infants.  With  an  American 
Supplement,  edited  by  William  P.  Jenks,  M.D.  A  monthly  of  about  SO  octavo  pnges, 
very  handsomely  printed.  Subscription,  Five  Dollars  per  annum.  Single  Numbers,  50 
cents  each. 

Commencing  with  April,  1873,  the  Obstetrical  Journal  will  consist  of  Original  Papers  by  Brit- 
ish nnd  Foreign  Contributors  ;  Transactions  of  the  Obstetrical  Societies  in  England  and  abroad  ; 
Keports  of  Hospit:il  Practice;  Reviews  and  Bibliographical  Notices;  Articles  and  Notes,  Edito- 
rial, Historical,  Forensic,  and  Miscellaneous;  Selections  from  Journals;  Correspondence,  Ac. 
Collecting  together  the  vast  amount  of  material  daily  accumulating  in  this  important  and  ra- 
pidly improving  department  of  medical  science,  the  value  of  the  information  which  it  will  pre- 
sent to  the  subscriber  may  be  estimated  from  the  character  of  the  gentlemen  who  have  already 
promised  their  support,  including  such  names  as  those  of  Drs.  Atthill,  Robert  Barnes,  llENav 
Bennet,  Thomas  Chambers,  Fleetwood  Churchill,  Matthews  Duncan,  Grailv  Hewitt, 
Braxton  Hicks,  Alfred  Meadows,  W.  Leishjian,  Alex.  Simpson  Tyler  Smith,  Edward  J. 
Tilt,  Spencer  Wells,  &c.  Ac.  ;  in  short, the  representative  men  of  British  Obstetrics  and  Gynae- 
cology. 

In  order  to  render  the  Obstetrical  Journal  fully  adequate  to  the  wants  of  the  American 
profession,  each  number  will  contain  a  Supplement  devoted  to  the  advances  made  in  Obstetrics 
and  G3'na?cology  on  tliis  side  of  the  Atlantic.  This  portion  of  the  Journal  will  be  under  the 
editorial  charge  of  Dr.  William  F.  Jenks,  to  whom  editorial  communications,  exchanges,  books 
for  review,  Ac,  may  be  addressed,  to  the  care  of  the  publisher. 

*.::;.*  Gentlemen  desiring  complete  sets  will  do  well  to  forward  their  orders  without  delay. 


&o. 


rPHOMAS  [T.GAILLARD),M.D., 

•*-  Professor  nf  Obstetrics,  &c.,  in  the  Collfge  of  Physicians  and  Surgeons,  N.  Y., 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.    Third 

edition,  enlarged  and  thoroughly  revised.  In  one  large  and  handsome  octavo  volume  of 
784  pages,  with  246  illustrations.  Cloth,  $5  00;  leather,  $6  00.  (Jjist  Issued.) 
The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 
this  work  to  render  it  worthy  a  continuance  of  the  very  remarkaljle  favor  with  which  it  has  been 
received.  Every  portion  has  been  subjected  to  a  conscientious  revision,  several  new  chapters 
have  been  added,  and  no  labor  spared  to  make  it  a  complete  treatise  on  the  most  advanced  con- 
dition of  its  important  subject.  The  present  edition  therefore  contains  about  one-third  more 
matter  than  the  previous  one,  notwithstanding  which  the  price  has  been  maintained  at  the  former 
very  moderate  rate,  rendering  this  one  of  the  cheapest  volumes  accessible  to  the  profession. 

We  are  free  to  say  that  we  regard  Dr.  Thomas  the 


As  cornparml  with  the  first  edition,  five  new  chap- 
ters on  dysmenorrhiea,  peri-uterine  fluid  tniD^M-s, 
composite  turaor.s  of  the  ovary,  solid  tumors  of  the 
ovary,  and  chlorosis,  have  been  adiled.  Twenty- 
Seven  additional  wood  cuts  have  heen  introduceil, 
many  suhjects  have  been  subdivided,  and  all  have 
received  important  interstitial  increase.  In  fact,  the 
hook  has  been  practically  rewritten,  and  greatly  in- 
creased in  value.  Briefly,  we  may  say  that  we  know 
of  no  hook  which  so  completely  and  concisely  repre- 


best  American  authority  on  diseases  of  women.  Seve- 
ral others  have  written,  and  written  well,  but  none 
have  so  clearly  and  carefully  arranged  their  text  and 
instruction  as  Dr.  Thomas. — Oinoinaait  Lancet  and 
Observer,  May,  1872. 

We  deem  it  scarcely  necessery  to  recommend  this 
work  to  physicians  as  it  is  now  widely  known,  and 
most  of  them  already  possess  it,  or  will  certainly  do 
80.     To  students  we  unhesitatingly  recommend  it  as 


gents  the  present  state  of  gynajcology  ;  none  so  tail  i  the  besttext-book  on  diseases  of  females  extaut.-S< 

of  well-digested  and  reliable  teaching  ;  none  which     i,,.,,,-^  j^^.j   Reporter,  June,  1S69. 

bespeaks  an  author  more  apt  in  research  and  abun-  i       „-,-,,,,  ,     ^, 

dant  in  resources.— iV^.  Y.  Med.  Record  May  1,  1872  Of  all  the  army  of  books  that  have  appeared  of  lato 
\<r„  ,1,      Tj       1  1,    J   ■  ,..,',  ..'     .       I  years,  on  the  diseasesof  the  uterus  and  its  appendages, 

We  shot  Id  no    be  doing  our  duty  to  the  pro  ession     %,^  know  of  none  that  is  so  clear,  comprehensive,  and 

rtid  we  not  tell  those  who  are  unacipiainted  with  the  ...-_.  .    '  '    .  .'     .  . 

book,  how  much  it  is  valued  by  gynecologists,  and 

how  it  is  in  many  respects  one  of  the  best  text-books 

on  the  subject  we  possess  in  our  language.     We  have 

no  hesitation  in  recommending  Dr.  Thomas's  work  as 


one  of  the  most  complete  of  its  kind  ever  published 
It  should  be  in  the  possession  of  every  practitioner 
for  reference  and  for  6\.yxiy.—London'Lancet,  April 
27,  1S72. 

Our  author  is  not  one  of  those  whose  views  "never 
change."  On  the  contrary,  they  have  been  modified 
in  many  particulars  to  accord  with  the  progress  made 
in  this  department  of  medical  science:  hence  it  has  the 
freshness  of  an  entirely  new  work.  No  general  prac- 
titioner can  afford  to  be  without  it.— St.  Louis  Med. 
and  Sii.rg  Journal,  May,  1S72. 

Usable  author  need  not  fear  comparison  between 
it  and  any  similar  work  in  the  English   language; 


practical  as  this  of  Dr.  Thomas',  or  one  that  we  should 
more  emphatically  recommend  to  the  young  practi- 
tioner, as  his  guide. — California  Med.  Gazette,  June, 
1869. 

If  not  the  best  work  extant  on  the  subject  of  which 
It  treats,  it  is  cefrtainly  second  to  none  other.  So 
short  a  time  has  elapsed  since  the  medical  press 
teemed  with  commendatory  notices  of  the  first  edition, 
that  it  would  be  superfluous  to  give  an  extended  re- 
view of  what  is  now  firmly  established  as  the  American 
text-book  of  Gyuiecology. — N.  Y.  Med.  Gazette,  July 
17,  1869. 

This  is  a  new  and  revised  edition  of  a  work  which 
we  recently  noticed  at  some  length,  and  earnestly 
commended  to  the  favorable  attention  of  our  readers. 
The  fact  that,  in  the  short  space  of  one  year,  this 
second  edition  makes  its  appearance,  shows  that  the 
general  judgment  of  the  profession  has  largely  con- 


?7n7ZuZtl^ltY:!lVl'u^^'^'''''''  '""u^  f  ^^";?'     fi'-™ed  the  opinion  we  gave  at  that  thae.-Cincinnati 
f.i  piactitioners,  we  believe  It  is  unequal  led.     In  the     Lancet,  Aug.  ISiSQ. 


libriries  of  reading  physicians  we  meet  with  it 
oflener  than  any  other  treatis-eon  diseases  of  women. 
We  eonclnde  our  brief  re  view  by  rei-eating  the  hearty 
commendation  of  this  volume  givfa  when  we  com- 
menced :  if  either  student  or  practitioner  can  get  but 
one  book  on  diseases  of  women  tliat  book  should  be 
"Thoma,H."  —  Amtr.  Jour.  Med.  Sciences,  April, 
1S72. 


It  is  so  short  a  time  since  we  gave  a  full  review  of 
the  first  edition  of  this  book,  that  we  deem  it  only 
necessary  now  to  call  attention  to  the  second  appear- 
ance of  the  work.  Its  success  has  been  remarkable, 
and  we  can  only  congratulate  the  author  on  the 
brilliant  reception  his  book  has  received. — iV.  Y.  Med. 
Journal,  April,  1869. 


Henry  C.  Lea's  Publications — (Diseases  of  Women). 


23 


TTODOE  {HUGH  L.),  M.D., 

■'■-'•  EnuriiiiH  Proffxnor  itf  Ofintetrics,  A-n.,  in  the  Fviverfn'fy  nf  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN;  includincr  Bisj.lncements 

of  the  TTterns.  With  ori^rinal  illustrations.  Second  edition,  revised  and  enliirfced.  In 
one  beautifully  printed  octavo  volume  of  631  pages,  extra  cloth.  $4  50.  (Lately  Issued.) 
In  the  preparation  of  thi.s  edition  tho  author  has  spared  no  pains  to  improve  it  with  the  result3 
of  his  observation  and  study  durinc;  the  interval  which  ha.s  elapsed  since  the  first  apjiearance  of 
the  work.  Considerable  additions  have  thus  been  made  to  it,  which  have  been  partially  accom- 
modated by  an  enlargement  in  the  size  of  the  page,  to  avoid  increasing  unduly  the  bulk  of  the 
volume. 


Prom  Prof.  W.  H.  Btforo,  o/  the  Rush  Medical 
Onlli'ge,  Oh  ion  go. 

The  book  hpars  tlie  impress  of  a  master  hand,  and 
ranst,  as  its  pn'deopssor,  prove  acceptable  to  tlie  pro- 
fession. In  disoasps  of  women  Dr.  Hodge  has  estab- 
lished a  Rcliool  of  treatment  that  has  become  world- 
wide in  fame. 

Professor  Hodije's  work  is  truly  an  original  one 
from  beginnifl?  to  end,  conseciuently  no  one  can  pe- 
ruse its  pages  without  learning  something  new.  The 
book,  wliicli  is  by  no  means  a  large  one,  is  divided  into 
two  grand  sections,  so  to  speak  ;  first,  that  treating  of 
the  nervons  sympatliies  of  the  uterus,  and,  secondly, 
that  which  speaks  of  the  mechanical  treatment  of  dis- 
placements of  that  organ.  He  is  disposed,  as  a  non- 
believer  in   the  frequency  of  inflammations  of  the 


nterns,  to  take  strong  ground  against  many  of  tho 
highest  authoritips  in  this  brancli  of  lopilicinc,  aud 
the  arguments  which  he  ofiers  in  sujiport  of  his  posi- 
tion are.  to  say  the  least,  well  put.  Numorous  wood- 
cuts adorn  this  portion  of  the  work,  and  add  incalcu- 
lal)ly  to  the  proper  appreciation  of  the  variously 
shaped  instruments  referred  to  by  our  author.  As  a 
contribution  to  the  study  of  women's  diseases,  it  is  of 
great  value,  and  is  abundantly  able  to  stand  on  its 
own  merits. — TV.  Y.  Medical  Record,  Sept.  1.3,  1S68. 

In  this  point  of  view,  the  treatise  of  Professor 
Hodge  will  be  indispensable  to  every  student  in  its 
department.  The  large,  fair  type  and  general  perfec- 
tion of  woi-kraanship  will  render  it  doubly  welcome. 
— Pacific  Med.  and  Surg.  Journal,  Oct.  1868. 


TXTEST  (CHARLES),  M.D. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.    Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  extra 
cloth,    $3   75  ;  leather,  $4  75. 

The  reputation  which  this  volume  has  acquired  as  a  standard  book  of  reference  in  its  depart- 
ment, renders  it  only  necessary  to  say  that  the  present  edition  has  received  a  careful  revision  at 
the  hands  of  the  author,  resulting  in  a  considerable  increase  of  size.  A  few  notices  of  previous 
editions  .are  subjoined. 


The  manner  of  the  author  is  excellent,  his  descrip- 
tions graphic  and  perspicuous,  and  his  treatment  up 
to  the  level  of  the  time— clear,  precise,  definite,  and 
marked  by  strong  common  sense.  —  Chicago  Med. 
Journal,  Dec.  1861. 

We  cannot  too  highly  recommend  this,  the  second 
edition  of  Dr,  West's  excellent  lectures  on  the  dis- 
eases of  females.  We  know  of  no  other  book  on  this 
subject  from  which  we  have  derived  as  much  pleasure 
and  instruction.  Every  page  gives  evidence  of  the 
honest,  earnest,  and  diligent  searcher  after  truth.  He 
Is  not  the  mere  compiler  of  other  men's  ideas,  but  his 
lectures  are  the  result  often  years'  patient  investiga- 
tion in  one  of  the  widest  fields  for  women's  diseases — 
St.  Bartholomew's  Hospital.  As  a  teacher.  Dr.  West 
Is  simple  and  earnest  in  his  language,  clear  and  com- 
prehensive in  his  perceptions,  and  logical  in  his  de- 
ductions.— Gineiniiati  Lancet,  Jan.  1S62. 

We  return  the  author  our  grateful  thanks  for  the 
vast  amount  of  instruction  he  has  afforded  us.  His 
valuable  treatise  needs  no  eulogy  on  our  part.  His 
graphic  diction  and  truthful  pictures  of  disease  all 
speak  for  themselves. — Medieo-Chir ur g .  Review. 

Most  justly  esteemed  a  standard  work It 

bears  evidence  of  having  been  carefully  revised,  and 
is  well  worthy  of  the  fame  it  has  already  obtained. 
—Dub.  Med.  Quar.  Jour. 


As  a  writer.  Dr.  West  stands,  in  our  opinion,  se- 
cond only  to  Watsou,  the  "Macaulay  of  Medicine;" 
he  possesses  that  happy  faculty  of  clothing  instruc- 
tion in  easy  garments ;  combining  pleasure  with 
profit,  he  leads  his  pupils,  in  spite  oi^  the  ancient  pro- 
verb, along  a  royal  road  to  learning.  His  work  is  one 
which  will  not  satisfy  the  extreme  on  either  side,  but 
it  is  one  that  will  please  the  great  majority  who  are 
seeking  truth,  and  one  that  will  convince  the  student 
that  he  has  cummitted  himself  to  a  candid,  safe,  and 
valuable  guide.— iV.  A.  Med.-Chirurg  Review. 

We  must  now  conclude  this  hastily  written  sketch 
with  the  confident  assurance  to  our  readers  that  the 
work  will  well  repay  perusal.  The  conscientious, 
painstaking,  practical  physician  is  apparent  on  every 
page. — jV.  T.  Journal  of  Medicine. 

We  have  to  say  of  it,  briefly  and  decidedly,  that  it 
is  the  best  work  on  the  subject  in  any  language,  and 
that  it  stamps  Dr.  West  as  the  facile  princeps  of 
British  obstetric  authors. — Edinburgh  Med.  Journal. 

We  gladly  recommend  his  lectures  as  in  the  highest 
degree  instructive  to  all  who  are  interested  in  ob- 
stetric practice. — London.  Lancet. 

We  know  of  no  ti'eatise  of  the  kind  so  complete, 
and  yet  so  compact. — Chicago  Mtd.  Journal. 


B 


ARNES  (ROBERT),  M.D.,  F.R.C.P., 

Ob.stetric  Physician  to  St.  Thomases  Ho.s-pital,  &o. 

A  CLINICAL   EXPOSITION  OF   THE  MEDICAL  AND  SURGL 

CAL  DISEASES  OF  WOMEN.    In  one  handsome  octavo  volume  with  illustrations.     (Pre- 
paring.) 


CHURCHILL  ON  THE  PUEKPEKAL  FEA'EPv  AND 
OTHEU  DISE.^SES  PECULIAK  TO  WOMEN.  1  vol. 
8vo. ,  pp.  4J0,  extra  cloth.     $2  .50. 

DEWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition, 
with  the  Author's  last  improvements  and  correc- 
tions. In  one  octavo  volume  of  536  pages,  witt 
plates,  extra  cloth.     $.3  00. 

WEST'S  ENQUIRY  INTO  THE  PATHOLOGICAL 
IMPORTANCE  OF  ULCERATION  OF  THE  OS 
UTERI.     I  vol.  8vo.,  extra  cloth.     $1  2o. 


MEIGS  ON  WOMAN:  HER  DISEASES  AND  THEIR 
RE.MEUIES.  A  Series  of  Lectures  to  his  Class. 
Fourth  and  Improved  Edition.  1  vol.  Svo.,  over 
700  pages,  extra  cloth,  •'Jo  00  ;  leather,  *6  00. 

MEIGS  ON  THE  NATURE,  SIGNS,  AND  TREAT- 
MENT OF  CHILDBED  FEVER.  1  vol.  Svo.,  pp. 
36,'),  extra  cloth.     ij(12  00. 

ASHWELL'S  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  Loudon  edition  I  vol. 
8vo.,  pp.  528,  extra  cloth.     $3  50. 


24 


Henry  C.  Lea's  Publications — {Midwifery). 


fTODGE  {HUGH  L.),  31.  D., 

"^  EmKritus  Professor  of  Midwifery,  *e  ,  in  the  University  of  Pennsylvania,  &c. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  Illus- 
trated with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  extra  cloth,  $14 
The  wiirk  of  Dr.  Hodge  is  something  more  than  a       '"     '  .       .   «     . 


simple  presentation  of  his  particular  views  in  the  de- 
partment of  Obstetric? ;  it  is  soraetliine;  more  than  an 
ordinary  treatise  on  midwifery;  it  is,  in  fact,  a  cyclo- 
piedia  of  midwifeiy.  He  has  aimed  to  embody  in  a 
single  volume  the  whole  science  and  art  of  Obstetrics. 
An  elaborate  text  is  combined  with  accurate  and  va- 
ried pictorial  illustrations,  so  that  no  fact  or  principle 
is  left  unstated  or  unexplained. — Afii.  Med.  Times, 
Sept.  3,  ISti-t. 

We  should  like  to  analyze  the  remainder  of  this 
excellent  work,  but  already  has  this  review  extended 
beyond  our  liniiled  space.  We  cannot  conclude  this 
Rotice  without  referring  to  the  excellent  finish  of  the 
work.  In  typography  it  is  not  to  be  excelled;  the 
paper  is  superior  to  what  is  usually  afforded  by  our 
Aioerican  cousins,  quite  equal  to  the  best  of  English 
books.  The  engravings  and  lithographs  are  most 
beautifully  executed.  The  work  recommends  itself 
for  its  originality,  and  is  in  every  way  a  most  valu- 
able addition  to  those  on  the  subject  of  obstetrics. — 
Canada  Med.  Journal,  Oct.  lSfi4.  » 

It  is  very  large,  profusely  and  elegantly  illustrated,' 
and  is  fitted  to  take  its  place  near  the  works  of  great 
obstetricians.  Of  the  American  works  on  the  subject 
It  is  decidedly  the  best. — Edinb.  Med.  Joxir.,  Dec.  '6t 

**^  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  anj  address,  free  by  mail, 
en  receipt  of  six  cents  in  postage  stamps. 

/TANNER  {THOMAS  H.),  M.  D. 
ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.     First  Ameneaif 

from  the  Second  and  Enlarged  English  Edition.     AVith  four  colored  plates  and  illustrations 
on  wood.     In  one  handsome  octavo  volume  of  about  500  pages,  extra  cloth,  $4  25. 

The  very  thorough  revision  the  work  has  undergone     women  of  to-day,  so  commonly  associated  with  the 


We  have  examined  Professor  Hodge's  work  with 
grfat  satisfaction ;  every  topic  is  elaborated  most 
fully.  The  views  of  the  author  are  comprehensive, 
and  concisely  stated.  The  rules  of  practice  are  judi- 
cious, and  will  enable  the  practitioner  to  meet  eveiy 
emergency  of  obstetric  complication  with  confidence. 
— Chicago  Med.  Journal,  Aug.  1864. 

More  time  than  we  have  had  at  our  disposal  since 
we  received  the  great  work  of  Dr.  Hodge  is  necessary 
to  do  it  justice.  It  is  undoubtedly  by  far  the  most 
original,  complete,  and  carefully  composed  treatise 
on  the  principles  and  practice  of  Obstetrics  which  has 
ever  been  issued  from  the  American  press. — Pacifin 
Med.  and  Surg.  Journal,  July,  1S64. 

We  have  read  Dr.  Hodge's  book  with  great  plea- 
sure, and  have  much  satisfaction  in  expressing  our 
commendation  of  it  as  a  whole.  It  is  certainly  highly 
instructive,  and  in  the  main,  we  believe,  correct.  The 
great  attention  which  the  author  has  devoted  to  the 
mechanism  of  parturition,  taken  along  with  the  con- 
clusions at  which  he  has  arrived,  point,  we  think, 
conclusively  to  the  fact  that,  in  Britain  at  least,  the 
doctrines  of  Naegele  have  been  too  blindly  received. 
— Glasgow  Med.  Journal,  Oct.  1864. 


has  added  greatly  to  its  practical  value,  and  increased 
materially  its  efficiency  as  a  guide  to  the  student  and 
to  the  vonng  practitioner. — Am.  Journ.  Med.  Sci., 
April,  1S68. 

With  the  immense  variety  of  subjects  treated  of 
and  the  ground  which  they  are  made  to  cover,  the  im- 
possibility of  giving  an  extended  review  of  this  truly 
remarkable  work  must  be  apparent.  We  have  not  a 
6ingle  fault  to  find  with  it,  and  most  heartily  com- 
mend it  to  the  careful  study  of  every  physician  who 
would  not  only  always  be  sure  of  his  diagnosis  of 
pregnancy,  but  always  ready  to  treat  all  the  nume- 
rous ailojeuts  that  are,  unfortunately  for  the  civilized 


unction. — N.  Y.  Med.  Record,  March  16,  1S68. 
We  have  much  pleasure  in  calling  the  attention  of 

>ur  readers  to  the  volume  produced  by  Dr.  Tanner, 
the  second  edition  of  a  work  that  was,  in  its  original 
state  even,  acceptable  to  the  profession.  We  recom- 
mend obstetrical  students,  young  and  old,  to  have 
this  volume  in  their  collections.  It  contains  not  only 
a  fair  statement  of  the  signs,  symptoms,  and  diseases 
of  pregnancy,  but  comprises  in  addition  much  inter- 
esting relative  matter  that  is  not  to  be  fnund  in  any 
other  work  that  we  can  name. — Edinburgh  Med. 
Journal,  Jan.  1868. 


s 


WAYNE  {JOSEPH  GRIFFITHS),  M.  D., 

Physician-Accoucheur  to  the  British  General  Hospital,  &c. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 
MENCING MIDWIFERY  PRACTICE.  Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  Hutchins,  M.  D.  With  Illustrations.  In  one 
neat  12mo.  volume.     Extra  cloth,  $1  25.     (Noiv  Ready.) 

acswers  the  purpose.  It  is  not  only  valuable  for 
young  beginners,  but  no  one  who  is  not  a  proficient 
in  the  art  of  obstetrics  should  be  without  it,  because 
it  condenses  all  that  is  necessary  to  know  for  ordi- 
nary midwifery  practice.  We  commend  the  book 
most  favorably. — St.  Louis  Med.  and  Surg.  Journal, 
Sept.  10,  1870. 


It  is  really  a  capital  little  compendium  of  the  sub- 
ject, and  we  recommend  young  practitioners  to  bny  it 
and  carry  it  with  them  when  called  to  attpud  cases  of 
labor.  They  can  while  away  the  otherwise  tediou.? 
hours  of  waiting,  and  thoroughly  fix  in  their  memo- 
ries the  most  important  practical  suggestions  it  con- 
tains. The  American  editor  has  materially  added  by 
his  notes  and  the  concluding  chapters  to  the  com- 
pleteness and  gfjieral  value  of  the  book. — Chicago 
Med.  Journal,  Feb.  1S70. 

The  manual  before  us  containsin  exceedingly  small 
comp.iss — small  enough  to  carry  in  the  pocket — about 
all  there  is  of  obstefiics,  condensed  into  a  nutshell  of 
Aphorisms.  The  illustrations  are  well  selected,  and 
serve  as  excellent  reminders  of  the  conduct  of  labor — 
regular  and  difficult. — Cincinnati  Lancet,  April,  '70. 

"^v-isU  a  most  admirable  lit  tie  work,  and  completely 


A  studied  perusal  of  this  little  book  has  satisfied 
us  of  its  eminently  practical  value.  The  object  of  the 
work,  the  author  says,  in  his  preface,  is  to  give  the 
stud«nt  a  few  brief  and  practical  directions  respect- 
ing the  management  of  ordinary  cases  of  labor;  and 
also  to  point  out  to  him  in  extraordinary  cases  when 
and  how  he  may  act  upon  his  own  responsibility,  and 
when  he  ought  to  send  for  assistance. — iV.  T.  Medical 
Journal,  May,  1870. 


TF 


INC K EL  (F.). 

rrofessiir  and  Director  of  the  Gyncecologicul  Clinic  in  the  University  of  RnsfncTc. 

A  COMPLETE  TREATISE]  ON  THE  PATHOLOGY  AND  TREAT- 
MENT OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent  of 
the  author,  from  the  Second  German  Edition,  by  James  Read  Chadwick,  M  D.  In  one 
octavo  Volume.      {Prfjfariiig  ) 


Henry  C.  Lea's  Publications — {Midwifery). 


25 


JifErGS  [CHARLES  D.),  M.D., 

■*-^  Liilily  Prii/f.t.<i<ir  of  Ohyt,:lricn.  <<-f  ,  in  the,  Jnfff.rson  Medical  College,  Philadelphia. 

OBSTETRICS:   THE    SCIENCE    AND   THE   ART.     Fifth   edition, 

revised.     With  one  hundred  and  thirty  illustrations.     In  one  beautil'uUj'  printed  octavo 
yolume  of  7t)0  large  pagea.     Extra  clotii,  $5  60;  leather,  $f)  50. 
It  U  to  the  student  ttiat  our  author  haw  more  psir 


tlcularly  addressed  hiiiisflf ;  hut  to  tho  practitioner 
we  believo  it  would  be  equally  serviceable  as  a  book 
of  reference.  No  work  that  we  have  met  with  ^o 
thoroughly  details  everything  that  falls  to  the  lot  ol 
the  accoucheur  to  perform.  Kvery  detail,  uo  matter 
how  minute  or  how  trivial,  has  found  a  place.— 
Canada  ilfdic.alJuurnal,  July,  lSt>7. 
The  original  edition  is  already  bo  extensively  and 


favorably  known  to  the  profession  that  no  recom- 
mendation is  necessary  ;  it  is  sufflcient  to  say,  the 
present  edition  is  very  much  extended,  improved, 
and  perfected  Whilst  the  great  practical  ♦alents  and 
unlimited  experience  of  the  author  render  it  a  most 
valuable  acciuisition  to  the  practitioner,  it  is  so  con- 
densed as  to  constitute  a  most  eligible  and  excellent 
text-book  for  the  student.— i'ou^/t'-.rJi  Med.  and  liary. 
Journal,  July,  1S(J7. 


PAMSBOTHAM  [FRANCIS  IL),  M.D. 

THE  PRINCIPLES   AND    PRACTICE    OF   OBSTETRIC  MEDL 

CINE  AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  MMth  additions  by  W.  V.  Keating,  M.U., 
Professor  of  Obstetrics,  <fec.,  in  the  Jetierson  Medical  College,  Philadelphia.  In  one  large 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.     $7  00. 

To  the  physician's  library  it  is  indispensable,  while 
to  the  student,  as  a  text-book,  from  which  to  extract 
the  material  for  laying  the  foundation  of  an  education 
on  obstetrical  science,  it  has  no  superior. — Olao  Med. 
and  Surg.  Journal. 

When  we  call  to  mind  the  toil  we  underwent  in 
acquiring  a  knowledge  of  this  subject,  we  cannot  but 
envy  the  student  of  the  present  day  the  aid  which 
this  work  will  aiford  him. — Ai)i.  Jour,  of  the  Med. 
Sciences. 


We  will  only  add  that  the  student  will  learn  from 
It  all  he  need  to  know,  and  the  practitioner  will  find 
It,  as  a  book  of  reference,  surpassed  by  none  other. — 
Stethoscope. 

The  character  and  merits  of  Dr.  Ramsbotham's 
work  are  so  well  known  and  thoroughly  established, 
that  comment  is  unnecessary  and  praise  superfluous. 
The  illustrations,  which  are  numerous  and  accurate, 
are  executed  in  the  highest  style  of  art.  We  cannot 
too  highly  recommend  the  work  to  our  readers. — St. 
Louix  Med.  and  Surg.  Journal.  


pHURCHILL  [FLEETWOOD),  M.D.,  M.R.I.  A. 

ON  THE  THEORY  AND  PRACTICE  OP  MIDWIFERY.     A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.     With  notes  and  additions 
by  D.  Francis  Condie,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Chil 
dren,''  <fec.     With  one  hundred  and  ninety-four  illustrations.     In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.     Extra  cloth,  $4  00;  leather,  $5  00. 
In  adapting  this  standard  favorite  to  the  wants  of  the  profession  in  the  United  States,  the  editor 
has  endeavored  to  insert  everything  that  his  experience  has  shown  him  would  be  desirable  for  the 
American  student,  including  a  large  number  of  illustrations.     With  the  sanction  of  the  author, 
he  has  added,  in  the  form  of  an  appendix,  some  chapters  from  a  little  "Manual  for  Midwives  and 
Nurses,"  recently  issued  by  Dr.  Churchill,  believing  that  the  details  there  presented  can  hardly 
fail  to  prove  of  advantage  to  the  junior  practitioner.     The  result  of  all  these  additions  is  that  the 
work  now  contains  fully  one-half  more  matter  than  the  last  American  edition,  with  nearly  one- 
half  more  illustrations;  so  that,  notwithstanding  the  use  of  a  smaller  type,  the  volume  contains 
almost  two  hundred  pages  more  than  before. 


These  additions  render  the  work  .still  more  com- 
plete and  acceptable  than  ever;  and  with  the  excel- 
lent style  in  which  the  publishers  have  presented 
this  edition  of  Churchill,  we  can  commend  it  to  the 
profession  with  great  cordiality  and  pleasure. — C't?i- 
oinnati  Lancet. 

Few  work?  on  this  branch  of  medical  science  are 
equal  to  it,  certainly  none  excel  it,  whether  in  regard 
to  theory  or  practice,  and  in  one  respect  it  is  superior 
to  all  others,  viz.,  in  its  statistical  information,  and 
therefore,  on  these  grounds  a  most  valuable  work  for 
the  physician,  student,  or  lecturer,  all  of  whom  will 
find  in  it  the  information  whicli  they  are  seeking. — 
Brit.  Ain.  Journal. 

The  present  treatise  is  very  much  enlarged  and 
amplified  beyond  the  previous  editions  but  nothing 


ha.s  been  added  which  could  be  well  dispensed  with. 
An  examination  of  the  table  of  contents  shows  how 
thoroughly  the  author  has  gone  over  the  ground,  and 
the  care  he  has  taken  in  the  text  to  present  the  sub- 
jects in  all  their  bearings,  will  render  this  new  edition 
even  more  necessary  to  the  obstetric  student  than 
were  either  of  the  former  editions  at  the  date  of  their 
appearance.  No  treatise  on  ob.stetrics  with  which  we 
are  acquainted  can  compare  favorably  with  this,  in 
respect  to  the  amount  of  material  which  has  been 
gathered  from  every  source. — Boaton  Mvd.  and  Surg. 
■Journal. 

There  i.s  no  better  text-book  for  students,  or  work 
of  reference  and  study  for  the  practising  physician 
than  this.  It  should  adorn  and  enrich  every  medical 
library. — Chicago  Med.  Journal. 


M 


0NTG0MER7  [W.  F.),  M.D., 

Professor  of  Midioifery  in  the  King's  and  Queen's  College  of  Physicia ns  in  Ireland,. 


AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREG- 

NANCY.  With  some  other  Papers  on  Subjects  connected  with  Midwifery.  From  the  second 
and  enlarged  English  edition.  With  two  exquisite  colored  plates,  and  numerous  wood-cuts. 
In  one  very  handsome  octavo  volume  of  nearly  600  pages,  extra  cloth.     $3  75. 


KIGBY'S  SYSTEM  OF  MIDWIFERY.  With  Notes 
and  Additional  Illustrd.lions.  Second  American 
edition.  One  volume  octavo,  extra  cloth,  122  pages 
%%  -50. 


DEWEES'S  COMPREHENSIVE  SYSTEM  OF  MID- 
WIFERY.  Twelfth  edition,  with  the  author's  last 
improvements  and  corrections.  In  one  octavo  vol- 
auie,  extra  cloth,  of  t>CK)  pages.    13  60. 


26 


Henry  C.  Uea's  Publications — (Surgery). 


fyROSS  {SAMUEL  D.),  M.D., 

^J"  Proftssor  0/  Surgery  in  the  Jefferson  Medical  CoUege  of  Philadelphia. 

A  SYSTEM  OF  SURGERY:   Pathological,  Diagnostic,  Therapeutic, 

and  Operative.     Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.     Fifth  edition, 
carefully  revised,  and  improved.    In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pages,  strongly  bound  in  leather,  with  raised  bands,  $15.    {Jnst  Ready.) 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.    In  the 
present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  rei^pect  fully  up  to 
the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  enlarged  by 
nearly  one  fourth,  notwithstanding  which  the   price  has  been  kept  at  its  former  very  moderate 
rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  ol  matter  is 
condensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary  octavos. 
This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  binding,  renders 
it  one  of  the  cheapest  works  accessible  to  the  profession.     Every  subject  properly  belonging  to  the 
domain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this  work  may  be  3aid  to 
have  in  it  a  surgical  library. 

hesitation  In  pronouncing  it  without  a  rival  in  our 
language,  and  equal  to  the  best  .sy.stems  of  surgery  in 
any  language. — N.  T.  Med.  Journal. 

Not  only  by  far  the  best  text-book  on  the  subject, 
as  a  whole,  within  the  reach  of  American  students, 
but  one  which  will  be  much  more  than  ever  likely 
to  be  resorted  to  and  regarded  as  a  high  authority 
ibniad. — Am.  Journal  Med.  Sciences,  Jan.  1665. 

The  work  contains  everything,  minor  and  major, 
operative  and  diagnostic,  including  mensuration  and 
examination,  venereal  diseases,  and  uterine  manipu- 
lations and  operations.  It  is  a  complete  Thesaurus 
of  modern  surgery,  where  the  student  and  practi- 
tioner shall  noi  seek  in  vain  for  wiiai  they  desire.— 
San  Fi-aneisco  Med.  Press,  Jan.  IStio. 

Open  it  where  we  may,  we  find  sound  practical  in- 
formation conveyed  in  plain  language.  This  book  is 
no  mere  provincial  ur  even  national  system  of  sur- 
gery, but  a  work  which,  while  very  largely  indebted 
to  the  past,  has  a  strong  claim  on  the  gratitude  of  the 
future  of  surgical  science. — Edinburgh  Med. -journal, 
Jan.  1S65. 

A  glance  at  the  work  is  sufficient  to  show  that  the 
author  and  publisher  have  spared  no  labor  in  making 
it  the  most  complete  "System  of  Surgery"  ever  pub- 
lished in  any  country. — St.  Louis  Med.  and  Surg. 
Journal,  April,  18tio. 

A  system  of  surgery  which  we  think  unrivalled  in 
our  language,  and  which  will  indelihly  associate  his 
name  with  surgical  science.  And  what,  in  our  opin- 
ion, enhances  the  value  of  the  work  is  that,  while  the 
practising  surgeon  will  find  all  that  he  requires  in  it, 
it  is  at  the  same  time  one  of  the  most  valuable  trea- 
tises which  can  be  put  into  the  hands  of  the  student 
seeking  to  know  the  principles  and  practice  of  this 
branch  of  the  profession  which  he  designs  subse- 
quently to  follow. — Tlie  Brit.  Ain.Journ.,  Montreal. 


It  must  long  remain  the  most  comprehensive  work 
on  this  important  part  of  medicine. — Boston  Medical 
and  Surgical  Journal,  March  23,  IStjo. 

We  have  compared  it  with  most  of  our  standard 
works,  such  as  those  of  Erichseu,  Miller,  Feigusson, 
Syme,  and  others,  and  we  must,  in  justice  to  our 
author,  award  it  the  pre-eminence.  As  a  work,  com- 
plete in  almost  every  detail,  no  matter  how  minute 
or  trifling,  and  embracing  every  subject  known  in 
the  principles  and  practice  of  surgery,  we  believe  it 
stands  without  a  rival.  Dr.  Gross,  in  his  preface,  re- 
marks "my  aim  has  been  to  embrace  the  whole  do- 
main of  surgery,  and  to  allot  to  every  subject  its 
legitimate  claim  to  notice;"  and,  we  assure  our 
readers,  he  has  kept  his  word.  It  is  a  work  which 
we  can  most  confidently  recommend  to  our  brethren, 
for  its  utility  is  becoming  the  more  evident  the  longer 
it  is  upon  the  shelves  of  our  library. — Canada  Med. 
Journal,  September,  1S6j. 

The  first  two  editions  of  Professor  Gross'  System  of 
Surgery  are  so  well  known  to  the  profession,  and  so 
highly  prized,  that  it  would  be  idle  for  us  to  speak  in 
praise  of  this  work. —  Chicago  Medical  Journal, 
September,  1S6.5. 

We  gladly  indorse  the  favorable  recommendation 
of  the  work,  both  as  regards  matter  and  style,  which 
we  made  when  noticing  its  first  appearance. — British 
and  Foreign  Medico-Chirurgical  Review,  Oct.  IStJo. 

The  most  complete  work  that  has  yet  issued  from 
the  press  on  the  science  and  practice  of  surgery. — 
London  Lancet. 

This  system  of  surgery  is,  we  predict,  destined  to 
take  a  commanding  position  in  our  surgical  litera- 
ture, and  be  the  crowning  glory  of  the  authors  well 
earned  fame.  As  an  authority  on  general  surgical 
subjects,  this  work  is  long  to  occupy  a  pre-emineni 
place,  not  only  at  home,  but  abroad.     We  have  no 


UY  THE  SAME  AUTHOR. 

A   PRACTICAL    TREATISE    ON    FOREIGN    BODIES   IN  THE 

AIR-PASSAGES.     In  1  vol.  Svo.  cloth,  with  illustrations,     pp.  458.     $2  75. 


SKET'S   OPERATIVE  SURGERY.     In  1   vol.    Svo. 
cloth,  of  over  650  pages  ;  with  about  100  wood-cuts. 

COOPER'S  LECTURES  OX  THE  PRINCIPLES  AND 
Pkactice OF  Surgery,  Inl  vol.  Svo.  cloth,  7.50  p.  -$'2. 


GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUR- 
OERV.  Eighth  edition,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vel- 
umes,  about  lOUO  pp., leather,  raised  bands.  $6  50. 


lillLLER  {JA3IES), 

•*■'-'-  Late  Professor  of  Surgery  in  the  University  of  Edinburgh,  &e. 

PRINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and 

revised  Edinburgh  edition.     In  one  large  and  very  beautiful  volume  of  700  pages,  with 
two  hundred  and  forty  illustrations  on  wood,  extra  cloth,     %'i  lb. 
DF  THE  SAME  AUTHOR.  

THE   PRACTICE   OF   SURGERY.    Fourth  American,  from  the  last 

Edinburgh  edition.  Revised  by  the  American  editor.  Illustrated  hy  three  hundred  and 
sixty-four  engravings  on  wood.  In  one  large  octavo  volume  of  nearly  700  pages,  extra 
cloth.     $3  75. 


^ARGENT  {F.  W.),  M.D. 


ON  BANDAGING  AND  OTHER  OPERATIONS  OF  MINOR  SUR- 

GERY.    New  edition,  with  an  additional  chapter  on  Military  Surgery.    One  handsome  roya) 
lime,  volume,  of  nearly  400  pages,  with  ls4  wood-cuts.     Extra  cloth,  $1  76. 


Henry  C.  Lea's  Publications — (Surgery). 


27 


j^SHIIUKST  {JOHN,  Jr.),  M.D., 

Surgeon  to  the  Epincopnl  Hsopital,  Philadelphtn. 

THE    PRINCirLES   AND   PRACTICE   OF   SURGEPY.     In  one 

very  large  nnd  handsome  octavo  volume  of  ahout  1000  pages,  with  nearly  5J0  illustrations, 

extra  cloth,  $(i  50;  leather,  raised  bands,  $7  50.  (Just  Is-iueil.) 
The  object  of  the  author  has  been  to  ])resent,  within  as  condensed  a  compass  as  possible,  a 
complete  treatise  on  Surgery  in  all  its  branches,  suitable  both  as  a  text-book  for  the  student  and 
a  work  of  reference  for  the  j)ractitioner.  So  much  has  of  late  years  been  done  for  the  advance- 
ment of  Surgical  Art  and  Science,  that  there  seemed  to  Be  a  want  of  a  work  which  should  present 
the  latest  aspects  of  every  subject,  and  which,  by  its  American  character,  should  render  accessible 
to  the  profession  at  large  the  experience  of  the  jtractitioners  of  both  heuiisjiheres.  This  has  been 
the  aim  of  the  author,  and  it  is  hoped  that  the  volume  will  be  found  to  fulfil  its  purpose  satisfac- 
torily.    The  plan  and  general  outline  of  the  work  will  be  seen  by  the  annexed 

CONDENSED  SUMMARY  OF  CONTENTS. 

Chapter  I.  Inflammation.  II.  Treatment  of  Inflammation.  HI.  Operations  in  general: 
Anajsthetics.  IV.  Minor  Surgery.  V.  Amputations.  VI.  Special  Ami)utations.  VII.  Effects 
of  Injuries  in  General  :  Wounds.  VIII  Gunshot  Wounds.  IX.  Injuries  of  Bloodvessels.  X. 
Injuries  of  Nerves,  Muscles  and  Tendons,  Lymphatics,  Bursas,  Bones,  and  Joints.  XI.  Fractures. 
XII.  Special  Fractures.  XIII.  Dislocations.  XIV.  Effects  of  Heat  and  Cold.  XV.  Injuries 
of  the  Ilead.  XVI.  Injuries  of  the  Back.  XVII.  Injuries  of  the  Face  and  Neck.  XVIII. 
Injuries  of  the  Chest.  XIX.  Injuries  of  the  Abdomen  and  Pelvis.  XX.  Diseases  resulting  from 
Inilammation.  XXI.  Erysipelas.  XXII.  Pyaemia  XXIII.  Diathetic  Diseases:  Struma  (in- 
cluding Tubercle  and  Scrofula) ;  Rickets.  XXIV.  Venerea  1  Diseases  ;  Gonorrhoea  and  Chancroid. 
XXV.  Venereal  Diseases  continued  ;  Syphilis.  XXVI.  Tumors.  XXVTI.  Surgical  Diseases  of 
Skin,  Areolar  Tissue,  Lymphatics,  Muscles,  Tendons,  and  Bursas.  XXVIII.  Surgical  Disease 
of  Nervous  System  (including  Tetanus).  XXIX.  Surgical  Diseases  of  Vascular  System  (includ- 
ing Aneurism).  XXX.  Diseases  of  Bone.  XXXI.  Diseases  of  Joints.  XXXII.  Excisions. 
XXXIII.  Orthopasdic  Surgery.  XXXIV.  Diseases  of  Head  and  Spine.  XXXV.  Diseases  of  the 
Eye.  XXXVI.  Diseases  of  the  Ear.  XXXVII.  Diseases  ot  the  Face  and  Neck.  XXXVIII. 
Diseases  of  the  Mouth,  Jaws,  and  Throat.  XXXIX.  Diseases  of  the  Breast.  XL.  Hernia.  XH. 
Special  Herni.'B.  XLII.  Diseases  of  Intestinal  Canal.  XLIII.  Diseases  of  Abdominal  Organs, 
and  various  operations  on  the  Abdomen.  XLIV.  Urinary  Calculus.  LXV.  Diseases  of  Bladder 
and  Prostate.  XLVI.  Diseases  of  Urethra.  XLVII.  Diseases  of  Generative  Organs.  Index. 
Its  author  has  evidently  tested  the  writings  and  i      Indeed,  the  work  as  a  whole  must  be  regarded  as 

z ^1-   .1.  _     -.      -  ^    .   .     ]     .   ;  „     .1,  ^     .1,1^    I   «  ..     .,,.....11  .^..  .    .,  „  .4     «...«!.,.,    ^^^. *    .-.  P     ™...l 


experiences  of  the  past  and  present  in  the  crucible 
of  a  careful,  aDalyiic,  aud  h<inoialile  mind,  and  faith- 
fully endeavored  to  bring  his  work  up  to  the  level  of 
the  highest  standard  of  practical  surgery  He  is 
frank  and  detiaite,  and  gives  us  opinious,  and  gene- 
rally sound  ones,  instead  of  a  mere  resume  of  the 
opinions  of  others  lie  is  conservative,  but  not  hide- 
bound by  authority.  His  style  is  clear,  elegant,  and 
scholarly.  The  wi  rk  is  an  admirable  text  book,  and 
a  useful  book  of  reference  It  is  a  credit  to  American 
professional  literature,  and  one  of  the  first  ripe  fruits 
of  the  soil  fertilized  by  the  blood  of  our  late  unhappy 
war.— A',  r.  Med.  Record,  Feb.  1,  1S72. 


an  excellent  and  concise  exponent  of  modern  sur- 
gery, aud  as  such  it  will  be  found  a  valuable  text- 
book for  the  student,  and  a  useful  book  of  reference 
for  the  general  practitioner. — N.  Y.  Med.  Journal, 
Feb.  1872. 

It  gives  us  great  pleasure  to  call  the  attention  of  the 
profession  to  this  excellent  work.  Our  knowledge  of 
its  talented  and  acoomplished  author  led  us  to  expect 
from  him  a  very  valuable  treatise  upon  subjects  to 
which  he  has  repeatedly  giveu  evidence  of  having  pro- 
fitably devoted  much  tiaie  and  labor,  and  we  are  in  no 
way  disappointed.— PAi.'a.  J/cd.  Time*,  Feb.  1,  1S72. 


piERIE  (  WILLIAM),  F.  R.  S.  E., 

-*-  Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.    Edited  by 

John  Neill,  M.  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  to  the 
Pennsylvania  Hospital,  &c.  In  one  very  handsome  octavo  volume  of  780  pages,  with  336 
illustrations,  extra  cloth.     $3  75. 


H 


AMILTON  [FRANK  H.),  M.D., 

Professor  of  Fractures  and  Dislocations,  &c.,  in  Bellevrie  ffosp.  Med.  College,  Neuj  York. 

A  PRACTICAL  TREATISE   ON   FRACTURES  AND   DISLOCA- 

TIONS.  Fourth  edition,  thoroughly  revised.  In  one  large  and  handsome  octavo  volume 
ol  nearly  800  pages,  with  several  hundred  illustrations.  Extra  cloth,  $5  75  ;  leather,  $6  75. 
(Just  Issued. ) 

rable  treatise,  which  we  have  always  considered  the 
moi-t  complete  and  reliable  work  on  the  subject.  As 
a  whole,  the  work  is  without  an  equal  in  the  litera- 
ture of  the  profession. — Boston  Med.  and  Surg. 
Journ.,  Oct.  12,  1871. 

It  is  unnecessary  at  this  timetocommeod  the  book, 
except  to  such  ab  are  beginners  in  the  study  of  this 
particular  branch  of  surgery.  Every  practical  sur- 
geon In  this  country  and  abroad  knows  of  it  as  a  most 
trustworthy  guide,  and  one  which  they,  in  common 
wiih  us,  would  unqualifiedly  recommeud  as  the  high- 
e.xt  authority  in  any  language. — N.  Y.  Med.  Record, 
Oct   16,  1871. 


It  is  not,  of  course,  our  intention  to  review  in  ex- 
tenso,  Hamilton  on  "  Fractures  aud  Uislocations." 
Eleven  years  ago  such  review  might  not  have  been 
out  of  place  ;  to-day  the  work  is  an  authority,  so  well, 
so  generally,  and  so  favorably  known,  that  it  only 
remains  for  the  reviewer  to  say  that  a  new  edition  is 
just  out,  and  it  is  better  than  either  of  its  predeces- 
sors.— Cincinnati  Clinic,  Oct.  14,  1871. 

Undoubtedly  the  best  work  on  Fractures  and  Dis- 
locations iu  the  English  language. — Cincinnati  Med. 
Repertory,  Oct.  1871. 


We  have  once  more  before  us  Dr.  Hamilton's  admi- 


M 


ORLAND  [W.   W.),  M.D. 

DISEASES  OF  THE  URINARY  ORGANS;  a  Compendium  of  their 

Diagnosis,  Pathology,  and  Treatment.     With  illustrations      In  one  large  and  handsome 
octavo  volume  of  iibout  600  pages,  extra  cloth.     $3  50. 


28  Henry  C.  Lea's  Publications — (Surgery). 

PRICES  EN  {JOHN  E.), 

J-^  PraffiDS'ir  (if  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Sur- 

gical  Injuries,  Diseases,  and  Operations.  Revised  by  the  author  from  the  Sixth  and 
enlarged  English  Edition.  Illustrated  by  over  seven  hundred  engravings  on  wood.  In 
two  large  and  beautiful  octavo  volumes  of  over  1700  pages,  extra  cloth,  $9  00  ;  leather, 
$11   00.      {Jvst  Readij.) 

Anihor^s  Prfface  to  the  New  American  Edition. 

"  The  favorable  reception  with  which  the  '  Science  and  Art  of  Surgery'  has  been  honored  by  the 
Surgical  Profession  in  the  United  States  of  America  has  been  not  only  a  source  of^deep  gratifica- 
tion and  of  just  pride  to  me,  but  has  laid  the  foundation  of  many  professional  friendships  that 
are  amongst  the  agreeable  and  valued  recollections  of  my  life. 

"I  have  endeavored  to  make  the  present  edition  of  this  work  more  deserving  than  its  predecessors 
of  the  favor  that  has  been  accorded  to  them.     In  consequence  of  delays  that  have  unavoidably 
occurred  in  the  publication  of  the  Sixth  British  Edition,  time  has  been  afforded  to  me  to  add  to  this 
one  several  piragraphs  which  I  trust  will  be  found  to  increase  the  practical  value  of  the  work." 
London,  Oct.  1^72. 

On  no  former  edition  of  this  work  has  the  author  bestowed  more  pains  to  render  it  a  complete  and 
satisfactory  exposition  of  British  Surgery  in  its  modern  aspects.  Every  portion  has  been  sedu- 
lously revised,  and  a  large  number  of  new  illustrations  have  been  introduced.  In  addition  to  the 
materiiil  thus  added  to  the  English  edition,  the  author  has  furnished  for  the  American  edition  such 
material  as  has  accumulated  since  the  passage  of  the  sheets  through  the  press  in  London,  so  that 
the  work  as  now  presented  to  the  American  profession,  contains  his  latest  views  and  experience. 

The  increase  in  the  size  of  the  work  has  seemed  to  render  necessary  its  division  into  two  vol- 
umes. Great  care  has  been  exercised  in  its  tj'pographical  execution,  and  it  is  confidently  pre- 
sented as  in  every  respect  worthy  to  maintain  the  high  reputation  which  has  rendered  it  a  stand- 
ard authority  on  this  department  of  medical  science. 

These  are  only  a  few  of  the  points  in  which  the  states  in  his  preface,  they  are  not  confini^d  toanyone 
present  edition  of  Mv.  Erich.sen's  work  surpai-ses  its  '  portion,  but  are  distributed  generally  through  the 
predeces.sors.  Throughout  there  is  evideuce  of  a  ,  subjects  of  which  the  work  treats.  Certainly  one  of 
laborious  care  and  solicitude  in  seizing  the  passing  '  tbe  most  valuable  sections  of  the  book  seems  to  ns  to 
knowledge  of  the  day,  wliich  reflects  the  greate-t  be  that  which  treats  of  the  di-^eases  of  tbe  arteries 
credit  on  the  author,  and  much  enhances  the  value  '  and  theoperative  proceedings  which  they  necessitate, 
of  hiswork.  We  can  only  admire  the  industry  which  '  In  few  text-books  is  so  much  carefully  arranged  ia- 
has  enabled  Mr.  Eriehseu  thus  to  succeed,  amid  the  formation  collected. — London  Med.  Times  and  Gnz., 
distractionsof  active  practice,  in  producing  empliatic-  ■  Oct.  26,  lb72. 

ally  THE  book  of  reference  and  study  for  British  prac-         Ti,e  entire  work,  complete,  as   the  great  English 
titioners  of  surgery.— /,o)i(to«  X,aiic<  Oct.  26,  lt./2.     I  treatise  on  Surgery  of  our  own  time,  i;-,  we  can  assure 

Con.siderable  changes  have  been  made  in  this  edi-  !  our  readers,  equally  well  adapted  for  the  most  juuior 
tion,  and  nearly  a  hundred  new  illustrations  have  ■  student,  and,  as  a  book  of  reference,  for  the  advanced 
b«cn  added.   It  is  difficult  in  a  smati  compass  to  point     practitioner. — Dublin  Quarterly  Journal. 
out  the  aiteratijub  and  additions  ;  for,  as  the  author  I 


DF   THE  SAME  AUTHOR.     (Jtist  Issued.) 

ON    RAILWAY,    AND    OTHER    INJURIES   OF    THE    NERVOUS 

SYSTEM.     In  a  small  octavo  volume.     Extra  cloth,  $1  00. 


jyRUITT  (ROBERT),  M.R.C.S.,  ^c. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition  Illus- 
trated with  four  hundred  and  thirty-two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages.    Extra  cloth,  $4  00;  leather,  $5  00. 

All  that  the  surgical  student  or  practitioner  could  '  perspicuously,  as  to  elucidate  every  important  topic, 
desire. — D"Min  Quarterly  Journal.  '  The  fact  that  twelve  editions  have  already  been  called 

;  for,  in   these   days  of  active  compeiilion,  would  of 

It  is  a  most  admirable  book.     We  do  not  know  i  itself  show  it   to  possess   marked   superiority.     We 

have  examined  the  book  most  thoroughly,  and  can 
jay  that  this  success  is  well  merited.  His  book, 
moreover,  possesses  the  inestimable  advantages  of 
baving  the  subjects  perfectly  well  arranged  and  clas- 
•iilied,  and  of  being  written  in  a  style  at  once  clear 
md  succinct. — Am.  Journal  of  Med.  Sciences. 


when  we  have  examined  one  with  more  pleasure 
Boston  Med.  and  Surg.  Journal 


In  Mr.  Druitt's  book,  though  containing  only  some 
seven  hundred  pages,  both  the  principles  and  the 
practice  of  surgery  are  treated,  and  so  clearly  and 


ASHTON  {T.  J.). 
ON  THE   DISEASES,  INJURIES,  AND  MALFORMATIONS   OF 

THE  RECTUM  AND  ANUS;  with  remarks  on  Habitual  Con.stipation.  Second  American, 
from  the  fourth  and  enlarged  London  edition.  With  handsome  illustrations.  In  one  very 
beautifully  printed  octavo  volume  of  about  300  pages.     $3  25. 


JDIGELO  W  [HENRY  J.).  M.  D., 

■'-'  Prdfxsiir  (if  Surgery  in  the  Mn.'i.sarhu.setts  Med.  College. 

ON   THE   MECHANISM   OF    DISLOCATION  AND  FRACTURE 

OF  THE  HIP.  With  the  Reduction  of  the  Dislocation  by  the  Flexion  Method.  With 
numerous  original  illustrations.  In  one  very  handsome  octavo  volume.  Cloth.  $2  50. 
(Lately  Issued.) 


Henry  C.  Lea's  Publications — (Surgery). 


29 


B 


RYANT  [THOMAS),  F.R.C.S., 

Siiryum  In  Guj/'ti  Jfnsjiital. 

THE   PRACTICE    OP    SURGERY.     With  over  Five  Ilmidied  En- 

prnvinfcs  on  Wood.     In  one  large  nnd  very  handsome  octavo  volume  of  nearly  1000  png^s, 
extra  cloth,  $0  25;   leiither,  nii.seJ  bands,  $7  25.      {Just  llerdij.) 

The  diHtingiiishcd  reputation  ol' tlio  author  and  the  extended  experience  which  lie  has  enjoyed  as 
surgeon  to  one  of  the  largest  of  the  liondon  hospitals,  are  an  earnest  of  the  value  of  his  labors. 
Though  entitled  a  "  Practice  of  Surgery,"  it  will  bo  seen  by  the  subjoined  summary  of  the  contents 
that  it  is  by  no  means  confined  to  operative  surgery,  but  that  it  presents  also  a  view  of  the  prin- 
ciples which  should  guide  the  surgeon  in  his  daily  practice.  Nearly  all  of  the  very  full  series  of 
illustrations  have  been  prepared  expressly  for  the  work. 

STJIvUvOC-A.!?,-^    OF    COISTTEKTTS. 

Introduction. — i.  On  lUiiairand  Inllanunation.  ii.  On  Traumatic  Fever,  Reptiercmia,  and  Py- 
emia. III.  Un  Trismus  and  Tetanus,  iv.  Deliriiim  Tremens,  v.  Contusions:  Wounds  of  the  Scalp, 
Ulooil  Tumors,  Osteitis,  vi.  Injuries  of  the  Cranium,  vil.  Concussion  of  the  Hrain.  vill.  Injuries 
of  the  JJraiu  and  its  Membranes,  complicating  Fracture,  ix.  Compression  of  the  Brain,  x.  Ke- 
Fults  of  Injuries  to  the  Head.  xi.  On  Fractures  of  the  Skull,  xii.  The  Operation  of  Trephining. 
xur.  Dii^eases  of  the  Scalp  and  Cranium,  xiv.  Spina  Bifida,  xv.  Injuries  of  the  Spine,  xvi. 
Intra-Spinal  Intlammation,  Spinal  Paralysis,  Kailway  Concussion,  xvii.  Fractures,  Dislocations, 
and  Wounds  of  f^te  Spine,  xviii.  Curvatureof  the  Spine,  xix.  Injuries  and  Diseases  of  the  Nerves. 
XX.  Surgical  AfiTections  of  the  Nose.  xxi.  Surgical  Affections  of  Larynx  and  Trachea,  xxii.  Sur- 
gery of  the  Chest,  xxiii.  AVounds  of  the  Heart,  xxiv.  Diseases  of  the  Arteries,  xxv.  Aneurism. 
X.xvi.  Ligature  of  Arteries,  xxvn.  Injuries  and  Diseases  of  the  Veins,  xxvni.  Affections  of  the 
Lips,  etc.  XXIX.  Diseases  of  the  Jaws,  etc.  xxx.  Affections  of  the  Pharynx,  xxxi.  Injuries  of 
the  Abdomen,  xxxii.  Hernia,  xxxiii.  Varieties  of  Hernise.  xxxiv.  Trusses,  xxxv.  Surgery  of 
the  Anus,  xxxvi.  Diseases  of  the  Integuments  :  Wounds,  xxxvii.  Poisoned  Wounds,  xxxviii. 
Burns,  xxxix.  Skin  Grafting.  XL.  Boils,  etc.  XLi.  Gangrene,  etc.  xlii.  Ulcers,  xliii.  Mor- 
tification. XLiv.  Erysipelas,  xlv.  Diseases  of  the  Lymphatics.  XLVi.  Diseases  of  the  Kidney. 
XLVii.  Diseases  of  the  Bladder.  XLViii.  Diseases  of  the  Prostate.  XLix.  Urinary  Deposits,  l. 
Stone  in  the  Bladder,  li.  Lithotrity.  lii.  Lithotomy.  Liir.  Stone  in  the  Female  Bladder,  liv. 
Stricture  of  the  Urethra,  lv.  lletention  of  Urine.  Lvr.  Atiections  of  the  Penis.  Lvii.  Haemato- 
cele,  etc.  lviii.  Diseases  of  the  Testicle.  lix.  Sterility,  lx.  Affections  of  the  Female  Geni- 
tals. LXi.  Ovariotomy.  LXir.  Venereal  Disease.  Lxni.  Syphilis,  lxiv.  Tumors.  Lxv.  Anatomy 
of  Tumors,  lxvi.  Tumors  of  the  Breast,  lxvii.  Diseases  of  the  Thyroid  Gland,  lxviii.  Wounds 
of  the  Joints.  LXix.  Dislocations,  lxx.  Dislocations  of  the  Upper  Extremity.  Lxxi.  Disloca- 
tions of  the  Lower  Extremity,  lxxii.  Pathology  of  Joint  Diseases.  LXXiii.  Diseases  of  Special 
Joints.  Lxxiv.  Treatment  of  Joint  Disease,  lxxv.  E.xcision  and  Amputation  in  Joint  Disease. 
Lxxvi.  Osteo-arthritis.  lxxvii.  Diseases  of  the  Bones,  lxxviii.  Tumors  of  Bone,  lxxix.  Frac- 
tures. Lxxx.  Fractures  of  the  Upper  Extremity.  Lxxxi.  Fractures  of  the  Lower  Extremitj'. 
Lxxxii.  Complicated  I'racturcs.  lxxxiii.  Gunshot  Injuries,  lxxxiv.  Feigned  and  Hysterical  Dis- 
ease. Lxxxv.  Afl'ections  of  the  Muscles  and  Tendons,  lxx.xvi.  Ganglions,  lxxxvii.  Orthoptedic 
Surgery,  lxxxviii.  Ancesthetics.  Lxxxix.  Shock,  xc.  Amputation,  xcr.  Special  Amputations. 
xcii.  Elephantiasis,     xciii.  AiTections  of  the  External  Ear.     xciv.  Parasites. 


A 


^ELLS  {J.  SOELBERG), 

Professor  of  Ophthalmology  in  King'' 8  College  Hospital,  &c. 

TREATISE    ON    DISEASES    OF    THE    EYE.      First  American 

Edition,  with  additions  ;  illustrated  with  216  engravings  on  wood,  and  six  colored  plates. 
Together  with  selections  from  the  Test-types  of  Jaeger  and  Snellen.  In  one  large  and 
very  handsome  octavo  volume  of  about  750  pages:  extra  cloth,  $5  00;  leather,  $6  00. 
(Lately  Issued.) 


In  this  respect  the  work  before  us  is  of  much  more 
service  to  the  general  practitioner  than  those  heavy 
compilations  which,  in  giving  every  person's  views, 
too  often  neglect  to  specify  those  which  are  most  in 
accordance  with  the  author's  opinions,  or  in  general 
acceptance.  We  have  no  hesitation  in  recommending 
this  treatise,  as,  on  the  whole,  of  all  Eoglifh  works 
on  the  subject,  the  one  best  adapted  to  the  wants  of 
the  general  ^prAcxXixoner.  — Edinburgh  Mi-.d.  Journal, 
March,  1870. 

A  treatise  of  rare  merit.  It  is  practical,  compre- 
hensive, and  yetconcise.  Upon  those  subjects  usually 
found  difficult  to  the  student,  he  has  dwelt  at  leni{th 
aqd  entered  into  full  explanation.  After  a  careful 
perusal  of  its  contents,  we  can  unhesitatingly  com- 


mend it  to  all  who  de.sire  to  consult  a  really  good 
work  on  ophthalmic  science.  The  American  edition 
of  Mr.Wells' treatise  was  superintended  in  its  passage 
through  the  press  by  Dr.  I.  Minis  Hays,  who  has 
added  some  notes  of  his  own  where  it  seemed  desira- 
ble. He  has  also  introduced  more  than  one  hundred 
new  additional  wood-cuts,  and  added  selections  from 
the  test-types  of  Jaeger  and  of  Snellen. — Leavenworth 
Med.  Herald,  Jan.  1870. 

Without  doubt,  one  of  the  best  works  upon  the  sub- 
ject which  has  ever  been  published  ;  it  is  complete  on 
the  subject  of  which  H  treats,  and  is  a  necessary  work 
for  every  physician  who  attempts  to  treat  diseases  of 
the  eye. — Dominion  Med.  Journal,  8ept.  1869. 


TAWSON  {GEORGE),  F.  R.  C.  5.,  Engl, 

•*-'  As.s-istant  Surgeon  to  the  Royal  London  Ophthalmic  Hospital,  Moorfields,  &c. 

INJURIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS:  their  Imme- 

di.ate   and  Remote  Effects.      With  about  one  hundred  illustrations.      In  one  very  band- 
some  octavo  volume,  extra  cloth,  $3  60. 

It  is  an  admirable  practical  book  in  the  highest  and  best  sense  of  tke  phrase. — London  Medical  Timet 
and  OazeUe,  May  18,  1867, 


30  Henry  C.  Lea's  Publications— (Su^-g^ery,  &g.). 


L 


A  URENCE  [JOHN  Z.),  F.  R.  C.  S., 

Editor  of  the  Ophthalmic  Review,  d-c. 

A  HANDY-BOOK  OF   OPHTHALMIC   SURGERY,  for  the  use  of 

Practitioners.     Second  Edition,  revised  and  enlarged.     With  numerous  illustrations.     In 
one  very  handsome  octavo  volume,  extra  cloth,  §3  00.     (Lately  Issued.) 
For  those   however,  who  must  assume  the  care  of  ;  tion  of  the  optical  def^-cts  of  ahe  eye,  the  piiWisher 
diseases  and  injuries  of  the  eye,  and  who  are  too  !  has  given  increased  value  by  the  addition  of  several 


inj 
much  pressed  for  time  to  study  the  classic  works  on 
the  subject,  or  those  recently  published  by  Stellwag, 
Wells,  Bader,  and  others,  Mr.  Laurence  will  prove  a 
safe  and  trustworthy  guide.  He  has  described  in  this 
edition  those  novelties  which  have  secured  the  confi- 
dence of  the  profession  since  the  appearance  of  his 
last.    To  the  portion  of  the  book  devoted  to  a  descrip- 


pages  of  Snellen's  te.st-ty pes,  so  generally  used  to  test 
the  acuteness  of  vision,  and  which  are  difficult  to  ob- 
tain ill  this  country.  The  vohirtie  lias  been  conside- 
rably enlarged  and  improved  by  the  revision  and  ad- 
ditions of  its  author,  expressly  for  the  American 
edition — A.m.  Journ.  Mtd.  Sciencti,  Jan.  1870. 


jyALES  {PHILIP  S.),  M.  D.,  Surgeon  U.  S.  N. 


MECHANICAL  THERAPEUTICS:  a  Practical  Treatise  on  Surgical 

Apparatus,  Appliances,  and  Elementary  Operations  :    embracing  Minor  Surgery,   Band- 
aging, Orthopraxy,  and  the  Treatment  of  Fractures  and  Dislocations.     With  six  hundred 
and  forty-two  illustrations  on  wood.     In  one  large  and  handsome  octavo  volume  of  about 
700  pages:  extra  cloth,  $5  75;  leather,  $6  75. 
A  Naval  Medical  Board  directed  to  examine  and  report  upon  the  merits  of  this  volume,  ofiBeially 
states  that  "  it  should  in  our  opinion  become  a  standard  work  in  the  hands  of  everj-  naval  sur- 
geon ;"  and  its  adoption  for  use  in  both  the  Army  and  Navy  of  the  United  States  is  sufficient 
guarantee  of  its  adaptation  to  the  needs  of  every-day  practice. 


rfHOMPSON{SIR  HENRY), 

-*•  Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital. 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.   With 

illustrations  on  wood.     In  one  neat  octavo  volume,  extra  cloth.     $2  25. 
These  lectures  stand  the  severe  test.     They  are  in-    on  which  Sir  Henry  Thompson  speaks  with  more  au- 


Btructive  without  being  tedious,  and  simple  without 
being  ditfuse ;  and  they  include  many  of  those  prac- 
tical hints  so  useful  for  the  student,  and  even  more 
valuable  to  the  young  pi'actitioner. — Edinburgh  Med. 
Journal,  April,  1S69. 

Very  few  words  of  ours  are  necessary  to  recommend 
these  lectures  to  the  profession.     There  is  no  subject 


thority  than  that  in  which  he  has  specially  gathered 
his  laurels;  in  addition  to  this,  the  conversational 
style  of  instructiiin,  which  is  retained  in  these  printed 
lectures,  gives  them  an  attractiveness  which  a  sys- 
tematic treatise  can  never  possess. — London  Medical 
Times  and  Gazette,  April  24,  1S69. 


jyY  THE  SAME  AUTHOR. 

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHBA  AND  URINARY  FISTULA.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  extra  cloth,  $'6  50. 
(Lately  Published.) 

This  classical  work  has  so  long  been  recognized  as  a  standard  authority  on  its  perplexing  sub- 
jects that  it  should  be  rendered  accessible  to  the  American  profession.  Having  enjoyed  the 
advantage  of  a  revision  at  the  hands  of  the  author  within  a  few  months,  it  will  be  found  to  present 
his  latest  views  and  to  be  on  a  level  with  the  most  recent  advances  of  surgical  science. 

With  a  work  accepted  as  the  authority  upon  the  I  ably  known  by  the  profession  as  this  before  us,  mast 
Bubjects  of  which  it  treats,  an  extended  notice  would  |  create  a  demand  for  it  from  those  who  would  keep 
be  a  work  of  supererogation.  The  simple  announce-  I  themselves  well  up  in  this  department  of  surgery.— 
meat  of  another  edition  of  a  work  so  well  and  favor-  |  St.  Louis  Med.  Archives,  Feb.  1870. 


rPATLOR  {ALFRED  S.),  31. D., 

-*■  Lecturer  on  Med.  Jurisp.  and  Chemistry  in  &uy's  Hospital. 

MEDICAL  JURISPRUDENCE.     Seventh  American  Edition.     Edited 

by  John  J.  Reese,  M.D.,  Prof,  of  Med.  Jurisp.  la  the  Univ.  of  Penn.     in  one  large 
octavo  volume.      (Prejiariiig.) 

The  present  edition  of  this  trainable  mannal  is  a 
great  improvement  on  those  which  have  preceded  it 


It  makes  thus  by  far  the  beat  guide-book  in  this  de-     Journal,  Dec.  27,  IStJti. 


partment  of  medicine  for  students  and  the  general 
practitioner  in  ourlanguage. — Boston  Med.  aiidSurg. 


jnT  THE  SAME  AUTHOR.     (Nearly  Ready.) 

THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 

DENCE.     Second   Edition,   Revised,  with    numerous   Illustrations.     In    two   very  large 
octavo  volumes. 

This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  its  important  subject.  In  laying  it,  in  its  improved  form,  before  the  Ameri- 
can profession,  the  publisher  trusts  that  it  will  assume  the  same  position  iu  this  couutry. 


Henry  C.  Lea's  Publications — (Psycholoyical  Medicine,  &c.).      31 


rrUKE  [DANIEL  HACK),  M.D  , 

-*-  Joint  author  of  "  Tlie.  MdiiitaJ  of  I'siirJiolor/iciil  Medicine,"  etc. 

ILTAISTRATIONS  OF  THE  INFLUENCP]  OF  THE  MIXD  UPON 

THE  BODY  IN  JIKALTU  AND  DISEASE.  Desirrned  to  illu.striite  the  Action  of  the 
Iiniigiiiation.  In  one  hanJsouie  octavo  volume  of  416  pages,  eitra  cloth,  $.j  25.  {Now 
Ready.) 

The  object  of  the  author  in  this  work  ha.s  been  to  show  not  only  the  effect  of  the  niinfl  in  caus- 
ing and  intenfiifying  disease,  but  also  its  curative  influence,  and  the  use  which  may  be  made  of 
the  imagination  and  the  emotions  as  therapeutic  agents.  Scattered  facts  bearing  upon  this  sub- 
Ji'Cl  liave  long  been  familiar  to  the  profc-ision,  but  no  attempt  has  hitherto  been  made  to  collect 
and  systematize  them  so  as  to  render  them  available  to  the  practitioner,  by  establishing  the  seve- 
ral phenomena  upon  a.  scientific  basi.s.  In  the  endeavor  thus  to  convert  to  the  use  of  legitimate 
medicine  the  menus  vfhich  have  been  emjiloyed  so  successfully  in  many  systems  of  quackery,  the 
author  has  produced  a  work  of  the  highe.st  freshness  and  interest  as  well  as  of  permanent  value. 


ULANDFORD  [G.  FIELDING),  M.  D.,  F.  R.  C  P., 

J-^  Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  Sec. 

INSANITY  AND  ITS  TREATMENT:   Lectures  on  the  Treatment, 

Medical   and   Legal,  of  Insane  Patients.     With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on   the  Confinement  of  the  Insane.     By  Isaac  Rav,  M.  D.     In  one  very 
handsome  octavo  volume  of  471  pages:  extra  cloth,  $.3  25.      {Just  Issued.) 
This  volume  is  presented  to  meet  the  want,  so  frequently  expressed,  of  a  comprehensive  trea- 
tise, in  moderate  compass,  on  the  pathology,  diagnosis,  and  treatment  of  insanity.    To  render  it  of 
more  value  to  the  practitioner  in  this  country.  Dr.  Ray  has  added  an  appendi.\  which  affords  in- 
formation, not  elsewhere  to  be  found  in  so  accessible  a  form,  to  physicians  who  may  at  any  moment 
be  called  upon  to  take  action  in  relation  to  patients. 

It  satisfies  a  want  which  must  have  been  sorely  i  actually  seen  in  practice  and  the  appropriate  treat- 


felt  by  the  busy  general  practitioners  of  this  country. 
It  takes  the  form  of  a  manual  of  clinical  description 
of  the  various  forms  of  in.sanity,  with  a  description 
of  the  mode  of  examining  persons  suspected  of  in- 
8a,niiy.  We  call  particular  attention  to  this  feature 
of  the  book,  as  giving  it  a  unique  value  to  the  gene- 
ral practitioner.  If  we  pass  from  theoretical  c<inside- 
rations  to  descriptions  of  the  varieties  of  insanity  as 


ment  for  them,  we  find  in  Dr.  Blaudf.ird's  work  a 
considerable  advance  over  previous  writings  on  the 
subject.  His  pictures  of  the  various  forms  of  mental 
disease  are  so  clear  and  good  that  no  reader  can  fail 
to  be  struck  with  their  superiority  to  those  given  in 
ordinary  manuals  in  the  English  language  or  (so  far 
as  our  own  reading  extends)  in  any  other. — London 
Practitioner,  Keb.  1871. 


^TINSLOW  [FORBES],  M.D.,D.C.L.,^c. 

ON  OBSCURE  DISEASES  OF  THE  BRAIN  AND  DISORDERS 

OF  THE  MIND;  their  incipient  Symptoms,  Pathology,  Diagnosis,  Treatment,  and  Pro- 
phylaxis. Second  American,  from  the  third  and  revised  English  edition.  In  one  handsome 
octavo  volume  of  nearly  600  pages,  extra  cloth.     $4  25. 


EA  [HENRY  C). 
'  SUPERSTITION    AND    FORCE:    ESSAYS    ON    THE   WAGER   OF 

,  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.  Second  Edition, 
Enlarged.  In  one  handsome  volume  royal  12mo.  of  nearly  500  pages;  extra  cloth,  $2  75. 
{Lately  Published.) 

interesting  phases  of  human  society  and  progress.  .  . 
The  fulness  and  breadth  with  which  he  has  carried 
out  his  comparative  survey  of  this  repulsive  field  of 
history  [Torture],  are  such  as  to  preclude  our  doing 
justice  to  the  work  within  our  present  limits.  But 
here,  as  throughout  the  volume,  there  will  be  found 
a  wealth  of  illustration  and  a  critical  grasp  of  the 
philosophical  import  of  facts  which  will  render  Mr. 
Lea's  labors  of  sterling  value  to  the  historical  stu- 
dent.— London  Saturday  Review,  Oct.  8,  1870. 


We  know  of  no  single  work  which  contains,  in  so 
small  a  compass,  so  much  illustrative  of  the  strangest 
operations  of  the  human  mind.  Foot-notes  give  the 
authority  for  each  statement,  showing  vast  research 
and  wonderful  industry.  We  advise  our  eonfrires 
to  read  this  book  and  ponder  its  teachings. — Chicago 
Med.  Journal,  Aug.  1870. 

As  a  work  of  curious  inquiry  on  certain  outlying 
points  of  obsolete  law,  "Superstition  and  Force"  is 
one  of  the  most  remarkable  books  we  have  met  with. 
— Jjondon  Athenaam,  Nov.  .i,  1S<56. 

He  has  thrown  a  great  deal  of  light  upon  what  must 
be  regarded  as  one  of  the  most  instructive  as  well  as 


As  a  book  of  ready  reference  on  the  subject,  it  is  of 
the  highest  value. —  Westmiaster  Reoiew,  Oct.  Ibd?. 


B 


Y  THE  SAME  AUTHOR.    (Late  y  Published.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF   THE  TEM- 
PORAL POWER— BENEFIT  OF  CLERGY— EXCOMMUNICATION.   In  one  large  royal 

$2  - 


12mo.  volume  of  516  pp.  extra  cloth 

The  story  was  never  told  more  calmly  or  with 
greater  learning  or  wiser  thought.  We  doubt,  indeed, 
if  any  other  study  of  this  Held  can  be  compared  with 
this  for  clearness,  accuracy,  and  power.  —  Chicago 
Examiner,  Dec.  1870. 

Mr,  Lea's  latest  work,  "Studies  in  Church  History," 
fully  sustains  the  promise  of  the  hist.  It  deals  with 
three  subjects — the  Temporal  Power,  Benetit  of 
Clergy,  and  Excommunication,  the  record  of  which 
has  a  peculiar  importance  for  the  English  student,  and 
Is  a  chapter  on  Ancient  Law  likely  to  be  regarded  as 
final.  We  cau  hardly  pass  from  our  mention  of  such 
Works  as  these— with  which  that  ou  "Sacerdotal 
Celibacy"  should  be  included — without  noting  the 


75. 

literary  phenomenon  that  the  head  of  one  of  the  first 
American  houses  is  also  the  writer  of  some  of  its  most 
original  books. — London  Athenaum,  Jan,  7,  1871. 

Mr.  Lea  has  done  great  honor  to  himself  and  this 
country  by  the  admirable  works  he  has  written  on 
ecclesiologicalaud  cognate  subjects.  We  have  already 
had  occasion  to  comuieud  his  "Superstition  and 
Force"  and  his  "History  of  Sacerdotal  Celibacy." 
The  present  volume  is  fully  as  admirable  in  its  me- 
thod of  dealing  with  topic™  and  in  the  thoroughness^ 
a  quality  so  frequently  lacking  in  .American  authors — 
with  which  they  are  investigated. — N.  Y.  Journal  of 
Psychol  Medicine,  July,  1870. 


32 


Henry  C.  Lea's  Publications. 


INDEX    TO    CATALOGUE. 


PAGE 

American  Journal  of  the  Medical  Sciences  .      1 

American  Chemist  (The)  .         .         .         .         .11 

Abstract,  Half-Yeariy,  of  the  Med  Sciences  .  3 
Anatomical  Atlas,  by  Smith  and  Horner  .  ,  6 
Anderson  on  Diseases  of  the  Skiu  .         .        .20 

Ashion  on  the  Kectum  and  Anus  .        .        .        .28 

Attfield's  Chemistry 10 

Ashwell  on  Diseases  of  Females  .        .        .        .23 

Ashhurst's  Surgery 27 

Barnes  on  Diseases  of  Women  ,  .  .  ,23 
Bryant's  Practical  Surgery     .....     29 

Blandford  on  Insanity 31 

Basham  on  Renal  Diseases 18 

Brinton  on  the  Stomach 15 

Bigelow  on  the  Hip  ....  .     2S 

Barclay  s  Medical  Diagnosis  ...  .1-1 

Barlow's  Practice  of  Medicine  .  .  .  .1;' 
Bowman's  (John  E.)  Practical  Chemistry  .  .  10 
Bowman's  (John  E)  Medical  Chemistry  .  .  iO 
Buckler  on  Bronchitis     .        .       ■.        .        .        .17 

liumstead  on  Venereal 19 

Bumstead  and  CuUerier's  Atlas  of  Venereal  .  19 
Carpenter's  Human  Physiology  ....  8 
Carpenter's  Comparative  Physiology  ...  8 
Carpenter  on  the  Use  and  Abuse  of  Alcohol  .  13 
Carson's  Synopsis  of  Materia  Medica  .  .  .13 
Chambers  on  the  Indigestions  .  .  .  .  !•' 
Chambers's  Restorative  Medicine  .        .        .15 

Christison  and  Griffith's  Dispensatory  .        .     13 

Churchill's  System  of  Midwifery  ...  25 

Churchill  on  Puerperal  Fever  .  .  .  .23 
Condie  on  Diseases  of  Children  .  .  .  .21 
Cooper's  (B.  B)  Lectures  on  Surgery  .  .  |  26 
CuUerier's  Atlas  of  Venereal  Diseases  .         '     19 

Cyclopedia  of  Practical  Medicine  .  .  .  *  14 
Daltou's  Human  Physiology  .  ..."  9 
De  Jongh  on  Cod-Liver  Oil  .  ..."  13 
Dewees's  System  of  Midwifery  .  .  .  '25 
Dewees  on  Diseases  of  Females  .  .  .  '23 
Dewees  on  Diseases  of  Children  .  .  .  "21 
Druitt's  Modern  Surgery  .  .  .  .  •  28 
Dunglison's  Medical  Dictionary  ..."  4 
Dunglison's  Human  Physiology  .  .  .  •  9 
DuugUson  on  New  Remedies  .         .         .         '13 

Etlis's  Medical  Formulary,  by  Smith  ,  .  '13 
EricUsen's  System  of  Surgery  .  .  .  •  28 
Erichsen  on  Nervous  Injuries  .  .  .  -28 
Flint  on  Respiratory  Organs .         .         .         .         -17 

Flint  on  the  Heart •     17 

Flint's  Pr.ictice  of  Medicine  .  .  .  .  •  15 
F.iwnes's  Elementary  Chemistry  .  .  .  •  11 
Fox  ou  Diseases  of  the  Stomach     .        .         .         •     14 

fuUeron   the  Lungs,  &c '16 

(jreen's  Pathology  and  Morbid  Anatomy     .         •     14 

(iibson's  Surgery ■     20 

G luge's  Pathological  Histology,  by  Leidy    .        •     14 
Galloway's  Qualitative  Analysis  .         .         .         -10 
Gray's  Anatomy      .......       6 

Griffith's  (R.  E.)  Universal  Formulary  .        •     12 

Gross  on  Foreign  Bodies  in  Air-Passages      .         •     26 
Gross's  Principles  and  Practice  of  Surgery  .         •     26 
Gross's  Pathological  Anatomy        .         .         .         .14 

Guersant  on  Surgical  Diseases  of  Children  .  .  21 
Hartshorne's  Essentials  of  Medicine  .        .     16 

Hartshorne's  Conspectus  of  the  Medical  Sciences  6 
Hamilton  on  Dislocations  and  FraciureB      .        .     27 

Heath's  Practical  Anatomy 7 

Hoblyn's  Medical  Dictionary        ....       4 

Hodge  on  Women 23 

Hodge's  Obstetrics 24 

Hodges'  Practical  Dissections  ....  6 
Holland's  Medical  Notes  and  Reflections  .  .  14 
Horner's  Anatomy  and  Histology        ...       7 

Hudson  on  Fevers IS 

Hill  on  Venereal  Diseases 19 

Hillier's  Handbook  of  Skin  Diseases  .        .     20 

Jones  and  Sieveking's  Pathological  Anatomy  .  14 
Jones  (C.  Handfield)  on  Nervous  Disorders         .     IS 

Kirkes'  Physiology 8 

Kaapp's  Chemical  Technology  .         .         .11 

Lea's  Superstition  and  Force         .        ,        .        ,     3i 


Lea's  Studies  in  Church  History 

La  Roche  on  Yellow  Fever     . 

La  Roche  on  Pneumonia,  &c. 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye 

Laycock  on  Medical  Observation 

Lehmann's  Physiological  Chemi.^try,  2  vols 

Lehmann's  Chemical  Physiology  . 

Ludlow's  Manual  of  Examinations 

Lyons  on  Fever        .... 

Maclise's  Surgical  Anatomy  . 

Marshall's  Physiology    . 

Medical  News  and  Library     . 

Meigs's  Obstetrics,  the  Science  and  the  Art 

Meigs's  Lectures  on  Diseases  of  Women 

Meigs  on  Puerperal  Fever 

Miller's  Practice  of  Surgery  . 

Miller's  Principles  of  Surgery 

Montgomery  on  Pregnancy     . 

Morland  on  Urinary  Organs  . 

Morland  on  Uisemia 

Neill  and  Smith's  Compendium  of  Med   Science 

Neligan's  Atlas  of  Diseases  of  the  Skin 

Neligan  on  Diseases  of  the  Skin 

Obstetrical  Journal 

Odling's  Practical  Chemistry 

Pavy  on  Digestion 

Prize  Essays  on  Consumption 

Parrish's  Practical  Pharmacy 

Pirrie's  System  of  Surgery     . 

Pereira's  Mat.  Medica  and  Therapeutics,  abridged 

Quain  and  Sharpey's  Anatomy,  by  Leidy 

Rauking's  Abstract  .... 

Radcliff  and  others  on  the  Nerves,  &c. 

Roberts  on  Urinary  Diseases  . 

Ramsbotham  on  Parturition  . 

Rigby's  Midwifery 

Rokitansky's  Pathological  Anatomy    . 
Royle's  Materia  Medica  and  Therapeutics 

Salter  on  Asthma 

Swayne's  Obstetric  Aphorisms 

Sargent's  Minor  Surgery 

Sharpey  and  Quains  Anatomy,  by  Leidy 

Simon's  General  Pathology    . 

Skey's  Operative  Surgery 

Slade  on  Diphtheria        .... 

Smith  (J.  L.)  on  Children 

Smith  (H.  H.)  and  Horner's  Anatomical  Atlas 

Smith  (Edward)  on  Consumption  . 

Smith  on  Wasting  Diseases  of  Children 

Solly  on  Anatomy  and  Diseases  of  the  Brai 

StiU6's  Therapeutics        .... 

Tanner's  Manual  of  Clinical  Medicine 

Tanner  on  Pregnancy 

Taylor's  Medical  Jurisprudence     . 

Taylor's  Principles  and  Pi;icticp  of  Med    Jurisp 

Tuke  on  the  Influence  of  the  Jlind 

Thomas  on  Diseases  of  Females 

Thompson  on  Urinary  Organs 

Thomp-on  ou  Stricture    . 

Todd  on  Acute  Diseases  . 

Wales  on  Surgical  Operations 

Walshe  on  the  Heart 

Watson's  Practice  of  Physic  . 

Wells  on  the  Eye    . 

West  on  Diseases  of  Females 

West  on  Diseases  of  Children 

West  on  Nervous  Disorders  of  Children 

West  on  Ulceration  of  Os  Uteri 

What  to  Ob.serve  in  Medical  Cases        . 

Williams's  Principles  of  Medicine 

Williams  on  Consumption 

Wilson's  Human  Anatomy     . 

Wilson  on  Diseases  of  the  Skin 

Wilson's  Plates  on  Diseases  of  the  Skin 

Wilson's  Handbook  of  Cutaneous  Medicine 

Wilson  on  Spermatorrhcea 

Winslow  on  Brain  and  Minrt 

Wiihler's  Organic  Ch<?mi-itry 

Winckel  on  Childbed 

Zeissl  on  Venereal  . 


PAOK 
31 


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